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MARION COUNTY BUILDING INSPECTION
<br />SENATOR BLDG, NO, 225
<br />220 HIGH STREET NE
<br /> SALEM, OREGON 97301
<br />
<br /> PHONE 588-5147
<br />CODE-A-PHONE 4:30 RM, - 8:00 A,M,
<br />
<br />I am performing work on aproperty I own or occupy,
<br />I am a registere¢ builder OR ( ) the authorize~ representative
<br />of a registered builder.
<br />The work will be performed by & registered builder.
<br />Other
<br />
<br /> I have read and agree to the terms stated on the reverse side of
<br /> this document.
<br />
<br />:}&]' E: 09/:3/89 T;ME:
<br /> P ] ';;FL,?,:DS, ?;AYS EL
<br />
<br />SIGNATURE OF APPLICANT:
<br />
<br /> DATE:
<br />
<br /> 577 ". ! '"'OaO
<br />
<br />CATEGORY:
<br />
<br />OCCUPANCY:
<br />
<br /> 2~5 CLEVELAND STREET
<br />Al, Iv!SV [ LLE "ON*
<br />
<br />USE OF BUILDING:
<br />
<br />97325
<br />
<br />CONTRACT CITY:
<br />
<br />UGB:
<br />
<br />NO
<br />
<br />OCCUPANT LOAD:
<br />
<br /> NO OF BEDROOMS:
<br />
<br />MAILING ADDRESS:
<br />
<br />SUBDIVISION:
<br />
<br />,q. IMSV I LLE CR 99325
<br />
<br /> SZTE NUMBER-' ~. 127
<br /> VALL;A?; ON:
<br />SBOTION: TOWNSHIP: RANGE: ZONEI
<br />
<br /> 24 8S 2~ RS
<br />AR~A: UNITS: IRREG. LOT: OORNER:
<br /> NO NO
<br />
<br />MAP:
<br />
<br />CONTRACTOR, NO.
<br />k. iCENSE'. NO:
<br />
<br />Po 8Ox 195
<br />aL.hvtSV~ LLE OR 9?325
<br />PMONE; 749-.-.2616
<br />
<br />PERr4_TT OR APPL~rCAT~ON NOr 18.,80!
<br />
<br /> UPERVI'~zNG ~.LE,.., ,'<*C.AN/N,JME{ER
<br />
<br />TWO OR MORE NEW CZRCU]TS,ALT OR EXT
<br />z ,FET SLIRCHARGE -ZONE 3
<br />EL. ECTRZCAL STATE SURCHARGE
<br />
<br />TOTAL ASSESSBB
<br />PREW;OUS RECE'r PTS
<br />TH[S RECE[ PT
<br />
<br />Qt,.i4 N T ! Tv AMOLiM T
<br /> 1 2,;30. G0
<br /> $3.84
<br />
<br />!,:39
<br />
<br />8A~,NCE ©L E $(7, . SS
<br />
<br />PAYEE: ~ECE ~PT NO
<br />g'EC? t, VED , Y: r,-'B ,TYP~ CHECK
<br />
<br />· * THIS IS A VALID PER~4IT/;,~ '~,]~flt~i,.,RERf4~T EXR'IRES/ 180,', DAY~]FROM ,.ITS I~E DATE. IF
<br />~ST~CTI~ C~ES FOR A~ P~','OF "~O"D~'?OR'~I'F",~TION FAILS TO MEET A~L
<br /> T
<br />RE~IIR~TS OF STATE ~ ~'~,~RI~' ~N~,,:BU'IBDI~G ,~D,,Z~NING ORDIN~CES, THIo PE~I,
<br />~AL_ BE~ME NULL ~D VOID ~
<br />
<br />Rg~ARKS: 2 CIR
<br />
<br />OCI~,A~..3 E. ~OODLEY, ~&R~0N CGUNTY ~U~LQ[N~OFF!CTAL / ~Y ,
<br />
<br />¢oR~ # ~c m..e .~v ~ee OFFICE COPY
<br />
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