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HomeMy WebLinkAboutPermit Mechanical 1995-12-8 . . . . VOOD STOVE/INSERT INSPECTION APPLICATION CITY OF SPRINGFEILD BUILDING SAFETY DIVISION 225 Fifth Street Springfield, Oregon 97477 Office: INSPECTION LINE: 726-3759 726-3769 .... Job Location: 3.'S 1?O S lZed~1 'OiL Assessors Map U: / ~6 2.. A c., /2- K,d< I Jlw(i~ 1-1"(:\ r.A. Address: 3.?~ 0 :;-R.t=>dJw(.)od i"d 12.. Ci ty: 5 ffttJt-h eJrf Value of Yood Stove/Pellet " Tax Lo t #: t<'J2 C-.t97:J Ollner: Phone: #: 9~'?;-7;;<g ? 97t.t7<6 State: ~ Stove/Insert:~ Zip Code: '7~O~ Preliminary Inspection is $15.00 (prior to installation of insert) Yood Stove/Pellet/Insert Permit is $15.00 + $.75 state surcharge + $.45 administrative fee + $10.00 issuance = $26.20 total Type of Insp~ction Requested: Pe....L lei 5' --bJ~. / c;9 s 8rec.J:we11 FS~lf Contractor: ({)w~.r R f'lJ ux:od Address: K,pJ. d~ Signature /2/0' /9S-- Da te, ' ======================================================================================= Date of Application: FOR OFFICE USE YOODST~NSERT /9-/s;!../'Lr ( / ? h. 2.0 PRELIMINARY REQUIRED INSPECTION(S): Job #: C)<:;"/ ~ 7 C; Total Amount Collected: Receipt #: /7 77 ~ Issued By: .~~~ Checked for Historical Status: '-Checked for Deliquencies: '~