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MARION COUNTY BUILDING INSPECTION <br />· ., SENATOR BLDG, NO, 225 <br /> 220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> 24 HOUR CODE-A-PRONE: 588-7904 <br /> <br /> I am a regbtered builder OR the authorized rep eson a ye s GNATURE <br /> Ota registered builder, <br /> The work wJtl be periormed by a registered builder, <br /> Other <br /> I have read and agree to ,he terms stated On the reverse 8ida of DATE: <br /> <br /> 5-N <br /> <br /> DE]'ROIT OR 97;'¢ 4,2 ~NTY <br /> <br /> HOSPITALS AND Of HER tI'ISTITUTIONAL ~UILDINJ;S <br /> <br />PO BOX 608 <br />SHELIOtq 1,1A 98584 <br />PHONE: 2(~6,,-264.-6226 <br /> <br />BREIT <br /> <br /> LOWER CAHP <br /> <br />NUHBER: 94-~4282 <br /> !I;~0,000.08 <br /> <br />: 20 I 9S i 71-'-.' <br /> <br />PERHIT OR APPLICATI~ <br /> <br /> I'rEi~ / <br />PLAN REVIEW <br />BIJiL. DING SI'AfE !~URCHARt;E / <br />Z('JN I I',1(;, [;URCI"IARGE <br /> / <br /> <br />' MAP: <br /> <br />ARCHI TECT/ENG IFIEEI~ ~ NO. <br /> <br />PHONE: <br /> <br />QSANT ITY <br /> <br />S193,, ~0 <br /> <br /> ~, 9 ,, 65 <br /> $9,, 65 <br /> <br />TOTAL ASSESSED FEE8 <br />PREVIOUS RECEIPTS $0,09 <br />Tills RECEIPT $3;37.75 <br /> <br />BALANCE DUE $0.80 <br /> <br />6.'~)44 <br /> <br />¢OLLOWIN6 ~UST BE <br />kk NECESSARY <br /> <br />PLAN <br /> <br />C:f: i'Y JURI!DI[ <br /> <br />THIS APPLICATION flUST GO THROUGHA REVIEW PROCESS WHERE THE <br /> IT IS. THE RESPONSIBILITY ~F THE APPLICANT TO ASSURE THAT <br /> BEEN PROVIDE9. <br /> <br /> DATE ~EtGHT.' l..'~ SETI)ACKS;: FR <br /> ~ATE .......................... TOTAL SQ F:'T: 728 LS ...... <br /> I)A~'E .................. STORIES: ~ ]:~S ...... <br /> ........................ PI.AN. A~TIOW: RR ......... <br /> J)DTE ENERGY PATi-h ............. <br /> <br />FORM # Md 1~-¢6 A~V, 4/90 OFFICE COPY <br /> <br /> <br />