HomeMy WebLinkAboutPermit Mechanical 1990-10-26
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Office:
INSPECTION LINE:
726-3759
726-3769
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Job Lo ca t i on: LY' I . I ( V' ~LJL1 '\.....lJJ Ll(.J0L)
Assessors Map #: \ '1 O~ 34 LfL'-
Owner: (Da1J11J~ GOLlliJlb ,
Address' (0 0r9J1) \ fA.S-.pY~i-%t> Phone I: fJlJlo toEXJQ
City: 8J}J~ State: @j~A17~ Zip: Cff)Lj1JR
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Value of Vood~tove/Pellet Stove/Insert:' ,
(please circle appropriate appliance)
Tax Lot #:
.
001-0 (jJ
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert perm:y't 's $15.00 + ~state surcharge +
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Type of Inspection Requ~d A p ll~) ,
Contractor: ~'~) ,-
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$10.00 Issuance
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 Vood Stove Safety information for wood burning
appliances and preliminary inspection standards. I also understand that if I am
req sting a preliminary inspection, the wall covering may be required to be removed.
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SIgna ture /
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Date
FOR OFFICE USE
REQUIRED INSPECTION(S): VOODSTOVE/PELLET/INSERT
Date of Application: ;1~~(). L;7~,)
Total Amount Collected: (~. ~ ' ~ ~
Receipt I,JBfotlf;'L, Issued BY'~.lf)~~
Checked for Delinquencies: ~ Checked for Historical
Job #:
PRELIMINARY
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Status:
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