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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 - <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I Am pert0rming work on a property [ own or occupy <br />I am a registered builder OR the authorized representative SIGNATURE OF APPLICANT: <br />of a registered builder. <br />The work will be performed by a registered builder· <br />Other <br />I have read and agree to the terms stated on the reverse side et DATE: <br />this document, <br /> <br /> KA:f:I...k;Y,~ JOF'IFJ H. <br />imYus ADdA~¢: ......... <br /> <br />TAX LOT: <br /> <br /> 74730-010 <br />CONSTRUCTION TYPE: <br /> <br /> PHONE: ?43-6222 <br /> <br /> ...................... [ ......................... 2& .................... 85. <br />;WIDTH' DEPTH; AR~ UNITS; <br /> <br /> : RE8 t :OENT [ AL, <br /> J OCCUPANCY'. <br />UGS OcCuPANT LOAD; <br /> <br /> ......... No. O~ BEOROOMS <br /> <br />._~Hg..XI.gg~LEN <br /> <br /> SITE NUMBER: <br /> VALUAT]:ON: <br /> <br />........................~ANGE: r~)NE' MAP: <br /> <br /> RREG LOT' ,CORNER; <br /> NO ' YES <br /> <br />TYPE= ~ECHANZCAL PER~IT 8R APPLICATION NO= <br /> <br />GAS ¢OI'INECTION <br />DONE:STSC WOOD STOVE <br />E, AD WAFER D,,tEA~ER <br />MECHANICAl., BASE FEE <br />Mf.;CI-IAHICAL STATE SURCHARGE <br /> <br />F:'AYEI~: blAIkK'"OI,K:: <br /> <br />57220 <br /> <br />'fOTAL ASSESSED FEES <br />PREvIOUSR~CEI'PT$ <br />TH.IS RECEIFT <br /> <br />~ALANCE DUE <br /> <br />QUANT:['?'Y AMOUNT <br />3 $6.00 <br />i $7..5~ <br />1 $7.5o <br /> $10,,08 <br /> $1,,55 <br /> <br />RECEIF'T NO: 59724 <br /> <br /> RITCE.[VEO BY: CL TYPE: £K CHECK ~: :1.250 <br /> * THIS IS A VALID PERMIT * THIS PERMIT EXPIRES 180 DAYS FROM ITS ISSUE BATE. IF <br />CONSTRUCTION CEASES FOR A PERIOD OF 188 DAYS, OR IF CONSTRUCTION FAILS TO MEET ALL <br /> EQUIREMENTS OF STATE LAWS ANB HA~I9N COOHTY BU!LBIN6 AND ZOHIN6 Q~BINANCES~ THIS PER~[T <br /> ALL BECOME NULL AND VOID. <br /> <br />k_~ARK,:*,. GAS WOODSfOYE,~ WATER HTR~ CI]OK STOVE <br />I)OH~LD IF:. WOIII;'L, EY,, ~'IAr<;?N (,DJIIFY BU'.IL:C'INI;, 8FF):C. IAL / })y ......................................................... <br /> <br />OFFICE COPY <br /> <br /> <br />