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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-G147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: G88-7904 <br /> <br />l am a registered builder OR { ) the authorized representative <br />Other_ <br /> <br />have read and agree to the terms stated on the reverse side of <br /> <br />ADDRESS: CONSTRUCTION TYPE: : OCCUPANCY: <br /> <br /> ~ ; R ".'~3 <br /> ~:~2 A~"~2],! ).~!~{ ,~-- ~,~ ~ CONTRACT CITY; : UGB; OCCUPANT LOAD: <br /> <br />TYPE: MANUFACTURED STRUCTURE <br /> <br />~1;577 Hi:L]. [:;r~k Rd <br /> <br />F'HI]Nf:T; 769.,.7744 <br /> <br />PERMIT OR APPLICATIgN HO: 9&§4&29 <br /> <br />TOTAL ASSESSED PE:ES <br /> <br /> PREV ]:OU.,] RECEZF'TS <br /> f lis <br />, BAL~NCE DUE <br /> <br />QUANT]:TY AMOUNT <br /> <br /> $29. <br /> $ 9 ,, <br /> <br />S21Z.I.O <br />$211,,10 <br /> <br /> P A Y ,S' E i: D e 1 H ,: C c - ¢ i c k ~' .... <br /> I I,l'~ O1C, E 5789? <br /> ................... ;: .......................... ;;.;...:R..;R..=.~ TYPE: ]:FI CHECK ~:: 0 <br /> <br /> ~ THIS IS NOT A PER,lIT. HUST gO THROUGH A REVIEW PROCESS WHERE THE <br /> FOLLO~IN~ MUST BE CQ~PLETEB; ::IT IS THE RESPQNSiB~LITY OF THE APPLICANT TO <br /> THAT ALL NECESSARY INFOREATIQN 'H~' BEEN <br /> <br />:, ,, . <br />O~ ,~ I ,(I ~g ,'%. TION,. <br />],'i.AN REV].EWr~ BY ~,~:~ ..... S~?fBACKS: FR :1,~ <br /> <br /> IG t,_ <br /> (:;.';Y , U, ,,, .r[O~.,. ~ DA~'F,: SP] ......... <br /> <br />FORM # MC 15-58 REV. 4/90 OFFICE COPY <br /> <br /> <br />