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MARION COUNTY BUILDING INSPECTION <br />SENATOR SLDG, NO, 225 <br />220 HiGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br />(-~,) I am a regir~tereq~ builder O¢~ ( ) the authorized representative <br /> of a registered builder, <br />{(~i The work witl be performed by a registered builder, <br /> Other <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> SI¢~NATUR~ OF APPLIDANT~__~, ,, ~, ~ <br /> <br />HAWORTH, DON ~ RESIDENTIAL <br /> <br /> J. 1~2~ FA~6O R~ NE ~O~TRACT Cl~'. .... ~ ~G~:~ .... ~CUPANt LOAD; <br /> AURORA OR 97062 ' ~( MARION COUNTY NO <br /> <br />SAME <br /> <br />PHONE: 678-5017 <br /> <br />SITE NUN]~R: <br />VALUATION: <br /> <br />93-82652 <br /> $20~000.,00 <br /> <br />TYPE: BUILDING PERHIT OR APPLICATION NO: <br /> <br />CONTRACTOR. NO. 00212 <br />Roger Way~'J~ Van Lieu <br />21~07 Oak Ln NE <br />Aurora, 97002-0000 x-~ .,.. <br />PFIOHE: 678-54~2 <br /> <br /> ITEM <br />~UILDING FEE <br />PLaN REVIEW <br />BUILDING STATE SURCHARGE <br />ZONING SURCHARGE <br /> <br />ARCHITECT/ENGINEER~ NO. <br /> <br />PHONE: <br /> <br />QUANTITY <br /> <br />TOTAL ASSESSED FEES <br />PREVIOUC~ECEIPTS <br />THIS RECEIPT' <br /> <br />AMOUNT <br /> $140.50 <br /> <br /> $7.0~ <br /> <br /> $0,00 <br />$245.8~ <br /> <br /> $0.00 <br /> <br />PAYEE: Roqe~ Sl16~ <br />RECEIVED BY. TYPE: CK CHECK ¢: 14294 <br /> <br />* TH~S IS NOT A PERNIT. ~THIS'APPCICRTION,HUST GO THROUGH A REVIEW PROCESS WHERE THE <br />FOLLO~HG HUST BE COHPL[T~<,I'? ZST~E/RESPONSi~ZL~TY:~F THE APPLICANT TO ASSURE TH*T <br /> LL NECESSARY INFORHAT~ON HAg BEEN PROVIDES, : <br /> <br /> DATE'~ --~ TOTAL SQ ~T: i14 LS', ~ <br /> <br /> PLAN. ACTION: <br /> CITY JURISDICTIOH: BY ............ gATE ............. ENERGY PAI'N: 1 SP__.~..~ <br /> EEHARKS= ADDZHG KIT HOOK REMOQEL BATH AN~ UTILITY /NO INCREASE IN BEg <br /> <br />FOR~ # ~C 15-S8 R~V. 4~ OFFICE COPY <br /> <br /> <br />