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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 8:00 - 4:30 <br /> <br />a'~ per ormlng work on a property I own or OCCUpy, <br />I am e registered builder OR ( } the authorized representat ve SIGNATURE OF APPUCANT; .... <br />O,her°f ~ registerad buddeL ................... /(~ /,~,,~ <br />The work will be performeb by a registered builder· ~.. . <br /> <br />_. ~ ............................ ~bO~A~ , <br /> <br />,,,,44.,,, ~ S I ~ ~ ~i_. <br /> <br />PH!',!NE: 263..-:J305 <br /> <br /> I T E H <br />BU I L,.'C. I NG FEE <br />,~'l... A N REVIEW <br />~UILD:[NG STATE SURCHARG£ <br />Z Cli,~ ]: I'.i(; SURCttARC, E <br /> <br />I:'A¥1,,i:,:,, T,,?4L, ES~ ChRL. F'~ <br /> <br />QUANTITY AMOUNT <br /> $ Og~,, 50 <br /> $52.3S <br /> <br /> $4. B3 <br /> <br /> 54498 <br /> CK CHECK 4~: 5476 <br /> <br /> :~W PROCESS WHERE THE <br /> 'LtCANT TO ASSUAE THAT <br /> <br />FORM # MC 15-51 RE'V, 4/~0 0 F FICE COPY <br /> <br /> <br />