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MARION COUNTY BUILDING INSPECTION <br />SENATOR I~LDG, NO. 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:S0 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am performing work on a property I own or occupy. <br />I am ~ registered builder OR ) the authorized representative <br /> <br />The work will be performed by a registered builder. <br />Other. <br /> <br />SIGNATURE OF APPLICANT: <br /> DATE; <br /> <br />OWNEF~: DA'T F ,~ <br /> <br /> MUi'IIZ~ E :: <br /> <br />TIME::: '~ .... ~" <br /> ......... 44 <br /> <br /> 860 5't FI <br /> 0 JHSV I I E <br />USE OF BUILDING; <br /> <br />OR 9 / S,.,,g <br /> <br />CONTRACT C TY <br /> <br /> AUHSV ELLEi: <br /> <br />MAILING ADDRESS: <br /> <br />CATEGORY: <br /> <br />OCCUPANT LOAD: <br /> <br /> NO OF BEDROOM~ <br /> <br />WiDTR: <br /> <br />PO BOX 951 <br />At.IMSVII,I,E ORE 97325 <br />F'HONE: 749-3507 <br /> <br /> BLOCK'. SECTION'. TOWNSHIF <br /> <br />SITE NUMBER: 5'5-1~{~745 <br />VAI._i. IA T I ON: <br /> RANGE ZONE <br /> <br /> ~RREG. LOT: CORNER <br /> 14.g NO <br /> <br />MAP: <br /> <br />TYPE: ~ECHANICAL <br /> <br />PERMIT OR APPLICATION bi0: <br /> <br />4~565 <br /> <br /> · '1: fEN QUAN r :1: I'Y <br />D[IN['SI'IC WOOI) 8'EOYE <br />/tECHANICAL BASE FEE <br />NECHAHIC. AI, STA'fE'. SURCHAR(;E <br /> <br />TOTAL A~S~$~E]) F'E;E$ <br />PREVIOUS I:~E[.,EI F'I 8 <br />'THIS REECE,I:F:' f <br /> <br />BALAHCE Dill[:. <br /> <br />$7.50 <br />$'1.0,, 00 <br /> <br />$18.38 <br /> ~1, 0., 00 <br />$ :1. 8., J 8 <br /> <br /> $0,, 8(,? <br /> <br /> PAYEE: HIIHtZ~ I'E~RI:~Y :l:;'I~l) :([: F[: 47786 <br /> Rli';CEIVE[ [Y: DH2 fY :': ~( CHECK 41:: '761 <br /> * THIS IS A VALI~ PERMIT ~ THIS PER~iT EXPIRES 188 DRYS FROM ITS ISSUE ~ATE. IF <br />CONSTRUCTION CEASES FOR A PERIO~ OF <br /> <br />REMARKS: <br />DOHAI,,,O <br /> <br />PIFI. LET ,:~rOVE: <br /> <br /> ~,,JOOI)I,.,EY,¢ HAR:[I]N OIJHfY 1~)UII...~IH(; OF'F'I'(Z:[AL / 8Y <br /> <br />OFFICE COPY <br /> <br /> <br />