|
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 /> 24 HOUR CODE-A-PHONE: 588-7904
<br />
<br />I am performing work On a property I OWn or OCCUpy, __~~ ,~.,~
<br />I am a registered builder OR ( ) the authori;~ed representative SIGNATURE OF APPLICANT~~ ~_.~
<br />o~ a registered builder.
<br />The work will be performed by a registered builger.
<br />Other
<br />I have read and agree to the terms stated on the reverse side of DATE:
<br />this document,
<br />
<br />OWNER:
<br />
<br /> I,h2 7 ~:'c . ~ r"-.F.,'~¥, .", :ti-' 3 ')~'.":'""~
<br />r Sif'u~ AOPR~: ! ~'TION YYPE'. ! OCCUPANCYI
<br />
<br /> '=-' ~'2 I UGh; IOGGUPANT LOAD:
<br /> . ~,,. ~: ~. ~',p_
<br /> ........ ~N0 0F BEDROOMS.
<br />
<br />TYPE: P].UMB 3:NC,
<br />
<br />90§2187
<br />
<br />PI,;ORE:;
<br />
<br />RE¢:[DEN'fZAL F':~X'IUF<E,¢ ALTER~,~T]:01,IS
<br />PL. UiSBI:NG ~{ASE FEE
<br />F'I..L1H)3~H(; STATE SURCHARGE
<br />
<br />(;~U A N-f':i] l"Y AHDU?4T
<br /> :t. s?.. 0~,
<br /> $20.80
<br /> ~, :1.,, 4 5
<br />
<br />PREVIOUS RECEIPTS ~,~),, ~)0
<br />
<br /> PA,,.,L. gA ...... iAf4...o t,, & i,,..IkO~. .... ~ ""*':"
<br /> F~ECEIF'T I0. ~ ......
<br /> ........ ;' ',' ~' TYF'E:; CK CI,{:,CK :Ih: ?<?4
<br /> RL ..Li /!_}) ., 1. Dl:~ .... ~ ...................... ;,,,.,,,,,~ .........
<br />
<br /> * THIS IS NOT A PERflI~. ,THIS ABPLiCATiQN HUST ~ THROUGH A REVIEW PROCESS WHERE THE
<br />FO~LOWIHG MDST BE COMPLETEg,~ IT IS THE ~ESPQHS[BILITY OF THE APPLICANT TO ASSU~E THAT
<br /> LL NECESSARY INFGR~ATIQN :,HA~ BEEN PROVIDER.'
<br />
<br /> '~:' ":' ,, C~TY 3~R~',SD];CTtON: BY ............................ I)A'I"E
<br /> PLAN B~ V ~k,, ~;~'¢ .......................... DATE ...............
<br />
<br /> REMA]:d<S;; ',i, F];X (KITCHEN)
<br />
<br />FORM # Mr 1~-§6 REV, 4/gO OFFICE COPY
<br />
<br />
<br />
|