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SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:3o <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am perfornq[ng woPk on a property I OWn or occupy. <br />I Am & registered builder OR the authorized represen 8 ve <br /> of 8 registered builder, <br />The work will be pettormed by a registere,4 builder, <br />Other ,, <br />I have read and agree to the terms stated on the reverse side of <br />this document. <br /> <br />SITUS ADDRESS: <br /> <br />~,/' OF DE?ROi:T <br /> <br />USE OF BUILDING; <br /> <br /> :LS~ DL:;I'ROU' AV <br />~,;E RD.IT ~d'R' ' --g'27;-~-2 <br /> <br />TAX LOT'. i CATEGORY'. <br /> I OCCUPANCY: <br /> }dG~:l ~ .,~,{~.'r-L~ ~L. ~ ' <br /> <br />LOT: SEOTION; TOWNSHIP: <br /> OR <br /> <br />WfBTN: AREA: -i UNITS: <br /> <br />75 74 <br /> <br />TYPE: <br /> <br /> ITEM <br />~:Iu.r. LD Z H6 <br /> <br />APPLICATION NB: <br /> <br /> P AY!EE,~ OF' DE'fROtl <br /> R ?". C I_-'; [ V DY:: <br /> <br />LL NI <br /> <br /> RANGE: j ZONE'. MAP <br />SITE HUMBER: '~ 94-f84:]~,i <br />YAI. I,]AITr-QNc ......... , ~450 ~ ~C4 <br />)RRE~, LOT: m CORNER; <br /> <br />62226 <br /> <br /> TYF'E: IN CHECK ,il,: 0 <br /> <br />~UST BE 68~P1.[]£~. If ~ THE ~EgPONSZB~LZTY OR THE ~PP£ICANT TO ASS(R~ TH&T <br /> INFORMATION HAS BEEN P~OV[DED, <br /> <br />HJ~]]:f,;J"IT: !]I.'"_"f'BACKStlF'R C <br />TOTAL St{ :'l",,: 8 [..S'"'¢/t <br />SI'ORZE S: RS ~ <br />PLAN. ASTION: HR' "(J <br />ENERGY PA'FHa; !~ !;', <br /> <br />REV, ~ OFFICE COPY <br /> <br /> <br />