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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 />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am a registered bu der OR ( ) the au hor zed rep esentat ve <br />of a registered builder, <br />The work will be performed by a registered builder, <br />Other <br /> <br />SIGNATURE OF ARPLICANT: <br /> DATE: .................. <br /> <br />MARTUSHEV,~ DANIEL ~ 7~8~-15~ RE~I3ENTIALe ~ <br /> <br /> 10831 gRN])T RD NE CONTRACT CITY: UGB: <br /> AURORA OR ~78~2 MARION COUNTY NO <br /> <br /> SITE NUHBER= 94-88777 ~ <br /> PHONE: 678-266B ~ VALUATION: , <br /> <br /> ~_ _ lgO I 18~. / SF ~ NO qO ' <br /> <br />TYPE: ELECTRICAL <br /> <br />OONTRACTO~ NO. <br />LICENSE Nu: <br /> <br />185 SE <br /> <br /> 266-6555 <br /> <br /> PERNIT OR APPLICATION NO: 9853175 <br />51161 SUPERVISING ELECTRICIAN/NUMBER <br /> <br />ToT:AL ASSESSED FEES <br />:PREVIOUS RECEIPTS <br />THIS,RECEIPT <br /> <br /> ITEM <br />LIMITED ENERGY <br />ELECTRICAL STATE SURCHARGE <br /> <br />QUANTITY AHOUNT <br /> 1 $20.00 <br /> $1.00 <br /> <br />$21.00 <br /> $0.00 <br /> $0.00 <br /> <br />$21.00 <br /> <br />PAYEE: RECEIPT NO: <br />RECEIVED BY: LD <br /> T~PE. CHECK ~: 0 <br />· THIS IS NOT A PERHIT. THIS REVIE~ PROCESS WHERE <br /> THE <br /> THAT <br /> <br />PLAN REVIEW: BY D -T~,r~-~r .... CITY JURISDICTION: BY DATE <br /> ........... ATE. .................................. <br />REMARKS: LIMITED ENERGY-ALARM~ CABLE:TV ' <br /> <br />FORM # MC 15-56 REV, 4/90 OFFICE COPY <br /> <br /> <br />