HomeMy WebLinkAboutPermit Mechanical 1991-1-2
VOOD STOVE/INSERT INSPECTION APPLICATION
CITY OF SPRINGFIELD
BUILDING SAFETY DIVISION
225 Fifth Street
Springfield, Oregon 97477
Job Location: I./""tj I.JLV6..&=;lLf::., UJAvI
Assessors Map #: \f1 (') ~ .::\ <9 i ~~ I
Owner: \)Ci\)l'\jlS. d IIcl.LLl h6Tc..HEIl
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Address: 4bt.JcJ ,JJLVc&f3Lt.e WJ4..CI
City:S:OI2J'u4-E/~.(> Sta/e: ,f2JL
. Value of lIood Stove~Stove~a Ic;?qg:'~
, (please circle a propriate a . ce)
Office: 726-3759
INSPECTION LINE: 726-3769
Tax Lot i:
()Cf'{)O
Phone i: 1!iJ~ 34 L/y ])4-17 Z" - " 'fJ 7
Zip: 97"'71"
Preliminary Inspection is $15.00 (prior to installation of insert)
Vood Stove/Pellet/Insert Permit is $15.00 +..... state surcharge +
Type of Inspection Requested: r ~tQ L(J)~ +':'~\.QQQQt
Contractor: Vhu...) L"Il=C (1AJs'7'il/JL'TIOJ
Address: .3110 A/, f!.L.I4lt.tTV'
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Ci ty: .1;, f.c. ~,,,
State:
nil
Construction Contractors Registration #:~~~'1
$10.00 Issuance
Phone i :t../fc I '.. 00 q I
Zip: ti)t{,O L
Expires: q Jq I
,
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
requesting a preliminary inspection, the wall covering may be required to be removed.
, A~~~, .rro.1tC-S~{ J.lJJ \(>~~l Kl:u_~ ~.
SIgnature /4 " , "
~\)I(~ \09;C(_\<\~FO~J:CE USE
REOUIREO INSPECTION( S): 1I00DSTO~E~INSERT
Date of Application: I~~ - ~' Job i:
Total Amount Collected: ,,\\,,9 ~ , 'f\ '
Receipt i:--LCJrn7 Issued By: ~\J)0L)
Checked for Delinquencies: '1,/'/
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Date
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l,.../' PRELIMINARY V
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Checked for Historical Status:
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