HomeMy WebLinkAboutPermit Mechanical 1990-3-28
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WOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office: 726-3759
INSPECTION LINE: 726-3769
6)4 CCJ a KUJ\(\t\ \..J\ }.\\ L-,
Assessors Map #: \ f) ()~ ~ 4-?1 Tax Lot #: 04 ill)
Owner: \\\ \\~. \~b , ~c\0\ \ ~N' h
Address: 04CC{} : 1) fJJ\~t\ \)\\" ~~ne -#: ~I\ ~!'\(B~
City: ~l0~_ State: I) lutJ ZiP:i['r4 If]
Value Of~O~ s~ove/Insert: f\ ~
(please circle approprlate'~, lancer ,
Job Location:
Preliminary Inspection is $15.00 (prior to
Wood Stove/Insert Permit is $15.00 + $0.75
Type of Inspection Re~ested: )
Con~ractor: \ \ /(1J
Address: /
/
installation of insert)
state surcharge
Phone #:
City:
State:
Zip:
Construction Contractors Registration #:
Expi res:
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
for wood burning appliances and preliminary inspection standards.
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ll~rratureJ . . ,
I FOR OFFICE USE
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Uate
REQUI'" INSPECTI'N(S), W", STDVIIINS"T ~"~ L-----' ----
Date of Application:_ 31fJ-S jqO Job #: 0\(J().?Jlc74
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Issued BRV JU../ . 1 \~
l_. Checked for Historical Status: (_) (jJ ~
Total Amount Collected:
Receipt #: I Lo~ I
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Checked for Delinquencies: