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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />· ¢~20 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am a registered builder OR ) the authorized representative SIGNATURE OF APPLICANT: ...... <br />Of a registered builder, <br />The work wiB be performed by a registered builder, <br />Other <br />i have read and ~gree to the terms stated on the reverse side o¢ DATE'. <br /> <br />COUNTY <br /> <br />70521!8 <br /> <br />PI"i[)NE:: 769'"'7q'5::J <br /> <br />(:~U A N'7':[ TY AN~3UN T <br /> 1 t;7.5¢ <br /> <br />TOTAL ABSESSED FEES <br />PREVIOUS RECE IF'TS <br /> <br />.k. <br /> <br /> ~AEANCE DOE ~1; ~ ,, <br /> <br /> F'AYEJ:E,': WALZ,, JAHES F',, & C¢~ROLYN S ~% REC[CI:P~?iO:~, , 54565 <br /> R=CrZW':,D ~,,, g~L,,,, ................................................................. <br /> <br />FOLLO~IN~ HUST BE CO~PLETE~. IT IS THE RESPONSIBILITY OF THE APPLICANT TO ASSURE THaT <br />LL NECESSARY TNFORMATION ~AS BEEN <br /> <br />FORM # MC 15-5B REV. 4/~O OFFICE COPY <br /> <br /> <br />