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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO, 225 <br />220 HIGH STREI=T NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br /> <br />I am performing work on a property I own or occupy. / <br />I Ar~ A registered builder OR the authorized representative SIGNATURE OF AI~PLICANT <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 of pATE: <br />this document. <br /> <br /> ...... ; 72651-311 RFSTDF:,F¥'ZAL <br /> AURORA OR 77~¢e2 ;MARIOb 6OUIqTY NO <br /> <br /> bAIZE.WOOD <br /> SAME SITE NUHBEE: <br /> PHONE: 678-:1.448 VALUATION: <br /> <br />,',-. '~ ~ ~ ~ ].-..~ .~ ~ ~.-~s .~ <br /> <br /> _' .... ZS_ ............ r_.ZZ <br />L I,Z~. 1~.~ .... : ~ S,- ~ YLS NO <br /> <br />TYPE.' <br /> <br />I¢)Nlf~AC,T,O,'~' '" <br />ThoMas [:yrzl SchoMLtS <br />2:t810 Boones <br /> <br /> ITEM <br />BUILDING FEE <br />PLAN REVIEW <br />BUILDING S'fATE SURCHARGE <br />ZON];NG SUI~CHARGE' <br /> <br />PERH~T aR APPLICATION NO: <br /> <br /> 9S56884 <br /> <br />ARCHI TECT/ENG;I;I~EEI% NO. <br /> <br />PHONE: <br /> <br />' ; i TOTAL ASSESSED FEES <br />:::i ' PREYTOUS RECE'fF'fS <br /> :: RECEIPT <br /> , <br /> <br />QUANT I:TY <br /> <br />AMOUNT <br /> $220.00 <br /> $24~.00 <br /> $11,00 <br /> $11.00 <br /> <br /> $~85,00 <br /> $0.00 <br /> $385,00 <br /> <br /> $0.00 <br /> <br /> RJ.,,CE].VE~ BY. CL ............ ~._.=;,~=_~__=_~.~:.=~z~z:. TYPE. CK CHI_Clx ~. 1.~6~ <br /> <br /> ~ THIS IS NOT A PERHIT:; THROU~H::A REVIEW PROCESS ~HEEE THE <br />FBLLOWIN~ HUST BE COHPLE:TE~,::; ::IT ;IS.~HE ': RESPQflSiBILITY OF THE APPLICANT TO ASSURE THAT <br /> LL HECESSARY IHFBRHATIQH H~S BEE~ PROVIB/~.: <br /> <br />:.7, OMIN..G,; ]E.,Y T/y.~r~;a]- --'DATE'-, ]~'~7_~4~_ TOTAL SQ F'T: <br />SEPT:[[;,~ BY ......................... ~:ATE "77 : - <br /> PLAM. ACTIOM: <br />Ci;i'Y JORI,E:;BIOT];OH. ;BY .............. ENERGY PATh. <br /> <br />........ " MAoTERBEDRM~IJOWER & F'A'HILY Rfl <br />it,MAkk,. RES/ADD <br /> <br />780 <br /> <br />SETBACKS: F';B/'~ <br /> LS"~" <br /> <br /> ;BF' ........... <br /> <br />OFFICE COPY <br /> <br /> <br />