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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 builder OR the authorized epresen a ye <br /> <br />The work will be performed by a registered builder, <br />Other <br /> <br />I have read and agree to the terms stated on the reverse side of <br />this document, <br /> <br /> 5-N <br /> 5758 F'ZL, BERT CREEK LANE .~E. <br /> AONSV II,.,LI.Z OR 9'7325 <br /> <br />;USE <br /> <br />' <br /> <br /> 2~4 NO. CENTER ST. <br /> SUBLIHITY ~738',] SITE NUHBER~ <br /> PHONE: 767-75~6 VALUATION: <br /> <br />i' <br /> <br />TYPE: BUILDING PERHIT UR APPLICATION <br /> <br />COIqTRACTOR,~ NO. <br />I(ILMARTIH~ PA';' <br />2:S4 HO. CENTER ST. <br />SUBLIMITY 9738~ <br />PHONE: 78~-7598 <br /> <br /> [TEH <br />BU~I. QIN6 FEE <br />PLAN REVIEW <br />BUILblNG STATE SURCHARGE <br />ZONING SURCHARGE <br /> <br /> 9~682~6 <br />ARCHt'FECT/ENGINEEI% <br /> <br />PHONE: <br /> <br />QLIANTI'rY <br /> <br />TOTAl. ASSESSED FEES <br />PREVIOUS RECEIPTS <br />THIS, RECEIPT <br />BAlANCE, DUE <br /> <br />AMOUNT <br /> $116.50 <br /> $75., 7~ <br /> $5.85 <br /> $5.83 <br /> <br />$203.89 <br /> $0.00 <br />$100.00 <br /> <br />$103.89 <br /> <br /> PAYEE: KILfiARTIN, PAT 82812 <br /> RECEIVED BY: js ........................................ TYPE: gA CHECK ~: 0 <br /> <br />ULLUeZN~ MU~/ BE COHPLETEO. IT,IS THE RESPONSIBILITY OF THE APPLICANT TO ASSOEE THaT <br />LL NECESSARY ZNFORNATIOH H~$ B~EH PROVIBEB. , <br /> q <br /> oEPTIC. BY ............... DAI'E~ .... STORIES: 1 RS-I~ <br /> CITY JUR.[o~ICTION: BY ............... DATE ............ ENEE6Y PATN: SF'"'/ <br /> REHAEKS: POLE BUILDIHG <br /> <br />OFFICE COPY <br /> <br /> <br />