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MARION COUNTY BUILDING INSPECTION
<br />SENATOR BLDG. NO. 225
<br />220 HIGH STREET NE
<br /> SALEM, ORSGON 97301
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<br /> PHONE: 588-5147 8:00 - 4:30
<br /> P4 HOUR CODE-A-PHONE: 588-7904 I/
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<br />{ ) I am pertormin9 work on a property t own or occupy.
<br />( '-~}-'I am a registered builder OR ( ) the ~uthorized representative SIGNATURE OF APPLICANT:~,.,~/~
<br /> of a registered budder,
<br />I / Other.I ) The w°rk will be P°rf°rrrled bY a register'ed builder' ~ f. ¢~/~
<br /> I have read and agree to ~he terms stated on the reverse side of DATE:
<br /> this document,
<br />
<br /> 5~!;' :[I'!TM ST .......
<br />
<br />USE OF BUILDING:
<br />
<br /> fD'l'H,:J;,' ',,If'}i,! -, P E~ ?, D E I?IT I ¢~L
<br />
<br />TAX I. OTI i'~ATE~ORY:
<br />
<br /> B~TE NUMBER:
<br /> VALUATION: !!il. ~ ~ 00!~., 80
<br />SECTION: .......... FTd~'~J SWI P'. RANGE: ........ ?~N'~i .......... ~A¢~ ....
<br />
<br /> A~¢ ........ U NIT~. ( ............................................... R~ LOT ,~ CORNE,. J ...... 5,, .'L
<br /> 252~)8 ........ SF ..... N{') .... riO", .--
<br />
<br />TYPE: BUILDING PERH:t'T OR APPLICATION
<br />C,.O,i,ITF;h~CTGF!~ NO , ;_'~: 12 ~,2
<br />
<br />12:I. 64 W S'tTay't':o'~ ~c , ~
<br />F-', , '"~'-'o,'"-
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<br />~¢Ui!.,I)Ih~G STATE SHRCHAR[~
<br />
<br />A F:C H I 'T'E C'F ? E big I N Jii:fi];l ,¢ NC.I.
<br />
<br />FILl qE. ,,
<br />
<br />'T'O'FAL ASSESSED F:EES
<br />.~{:;',J-"'t/]:,O, its .~Lt, E.[F f .
<br />
<br />9UAN?' ]: 't'Y
<br />
<br />'t~5/,'~ ,, 2L4
<br />$4 ,, J<!;
<br />
<br />· I J, ,, 7.59
<br />
<br />BALANCE DUE
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<br /> · :A,Y,E-' 4'c o1~ C'llSAI"L~","r I~"
<br /> EV D B',,, ~B I/V~ I~ ~"/~::'~:',, ~',,' ~', F,"," ,,, '~'~',
<br />· THZS ZS NOT A PERMZT. THIS APPL~CATZON "UST 60 THROUGH A'~'~'"'F~'~'"'~'~'~'"'{~[: .....................
<br />FOLLOWING MUST BE COMPLETED. ~T IS THE RESPOHSiiILiTY OF THE APPLICANT TO ASSURE THaT
<br /> LL NECESSARY tHFORNATION HAS ~EEH PROVIDED.
<br />
<br /> ,-'r:"',.' ,,.--.e,, ,.-.-..~.~
<br />TOTAL <"Fi ;'T~ :L2('/~ ,~-
<br />~'FOR:t:E/~ . i ~k:?'¢'v
<br />Ei.,.H~. aCT t CH,~:
<br />~,,~ E,M,Y ~ A ~ b;"'
<br />
<br />FORm # ~C ts.ss ney. 4/9e OF FICE COPY
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