HomeMy WebLinkAboutPermit Mechanical 1990-7-24 (2)
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SPRINGFIELD
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WOOO STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225'Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
Job Location: d R.:J"Y c: <:2/77 e Fa,eh/ !2q/
Assessors Map II: 17 0'< c:?OJ..<.fd /'/00 Tax Lot II: //0 <:)
Owner: I-kJe.n L,,,,dc:re.h -J"./'c L..'Jdyl'<:..... uJl k.
.Mdress: I /<f;;J.. ~ S. w, Rre.l1 i'1tIA-r. k Phone II: &, 3 (; , 900 ~
City: {J CJ~.I-) 4", J I State: (9 (' E' Zip: 9 7 a./ '7
Va 1 ue of Wood Stove/Insert: '~ .!3:ff).oO
(please circle approprlate appllanceJ
Preliminary Inspection is $15.00 (prior to installation of insert)
Wood Stove/Insert Permit is $15.00 + $0.75 state surcharge
Type of Inspection Requested: wood..s-bue.- Per""".,
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Contractor: L\ 'A K ('\ OLU .......
Address: Phone II:
City:
State:
Zip:
Co~struction Contractors Registration II:
Expires:
By signing this permit/application, I agree to call for an inspection(s) as
required (726-3769). I also state that all information on this application/
permit is correct and that I was provided with the Wood Stove Safety information
~WOOd burning appliances and preliminary inspection standards.
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19nature V (j 0_ uate
FOR OFF ICE USE
REQUIRED INSPECTION(S):
_ STOv"EpINSERT
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Date of Application:
Total Amount Collected:
Receipt #: I~
Issued By:
PRELIM I NARY
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Job II:
Checked for Delinquencies:
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Checked for Historical Status:
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