HomeMy WebLinkAboutPermit Mechanical 1991-6-5
YOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF 'SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726~3759
INSPECTION LINE: 726-3769
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Job Location:
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Assessors Map #: /70''3 ?> ~ 2.--; - ~1 3-3DO ' Tax Lot #: 17 03 ,3 ~ 'L..i -~3 c3 a~
Owner: ,1ZrnCLirJ LPrlt vJJr ~ J~~ 1k.-~
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Address: lU 4-4- I~ ~_:tC 20 Phone #:
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Ci ty: ~~ B" State:!T1.. Zip: ~ 7'+-'17
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Value of(Vood Stov;JPellet Stove/Insert: ~ ,()L/
(please circle appropriate appliance)
Preliminary Inspection is $15.00 (prior to installation of -insert)
Yood Stove/Pellet/Insert Permit is $15.00 + $10.00 Issuance + $1.25
, Type of 'Inspection Requested: ~ue~~~/.k~
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state surcharge.
Contractor:
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Address:
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expires:
By signing this permit/application, I agree to call for an inspection(s) as required
(726-3769). I state that all information on this application/permit is correct and
that I was provided with the YoodStove Safety information for wood burning
appliances and preliminary inspection standards. I also understand that if I am
requesting a preliminary inspection, the wall covering may be required to be removed.
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Signature
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Date'
FOR. OFFICE USE
Receipt fi:
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YOODSTOVE/PELLET/INSERT
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IS,.;)suu~eud y---- By: 12.dA~___
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Checked for Historical Status:
PRELIMINARY
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REQUIRED INSPECTION(S):
Date of Application:
Job it: 7 I () li7 CJ
Total Amount Collected:
Checked for Delinquencies:
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