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tXP I RE QARION COUNTY <br /> Building Application 5155 Silverton Rd NE <br /> NationSalem,OR 97305 <br /> county 503-588-5147 <br /> Authorization NA FAX: 503-588-7948 <br /> OREGON <br /> 555-21-007754-AUTH <br /> www.co.marion.or.us building@co.marion.or.us <br /> Applicant: Clean Slate, LLC <br /> 1553 WEDGEWOOD PL <br /> STAYTON, OR 97383 <br /> • <br /> TYPE OF WORK <br /> No Code Edition Specified <br /> Type of Work: Category of Construction: <br /> None specified Single Family Dwelling $0.00 <br /> Description of Work: FIRE -AUTH TO REPL 2 BDRM SFD W/2 BDRM SFD <br /> JOB SITE INFORMATION <br /> Property Address: Parcel: Owner: ELLIS,KAREN S <br /> 28681 North Fork Rd Se, Lyons,OR 97358 093E18BA01200 - Primary <br /> Address: 28681 NORTH FORK RD SE <br /> LYONS OR 97358 <br /> LICENSED PROFESSIONAL INFORMATION <br /> Business Name License Address Phone <br /> CLEAN SLATE,LLC Installer PO BOX 204 LYONS OR 97358 (50-3)-932- <br /> License <br /> PERMIT FEES <br /> Fee Description Quantity Amount <br /> Authorization notice-with field visit 1.00 Ea $450.00 <br /> DEQ Surcharge 1.00 Automatic $100.00 <br /> Total Fees: $550.00 <br /> Note:This may not include all the fees required for this project. <br /> This application will expire if application acceptance cannot be achieved within 180 days. <br /> All provisions of laws and ordinances governing this type of work will be complied with <br /> whether specified herein or not. <br /> All persons or entities performing work under this application are required to be licensed <br /> unless exempted by ORS 701.010. <br /> Printed on:07/30/2021 std_BuildingApplication_pr <br />