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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-S147 8:00 - 4:30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />~} IAmperformingworkonapropery owno occupy <br /> I am a reQistered builder OR the authorized represen ave SIGNATURE OF APPLIOANT~ <br /> of A registered builder, <br /> The work will be perfbrmed by a registered builder. <br /> Other <br /> I have read and agree to the terms 8tared on the reverse side of DATE: <br /> this document. <br /> <br /> .'-;'Tr:'uAF;;T,~ t,J:..I. ZF~, & ' ' <br />SITUS AODR~S§ <br /> <br /> 5-.-N <br /> ¢~URO~A ~R 77~2 ~A~¢.~ )N COUNTY <br /> <br /> ,.,,:NTUFY~ ~EAI)~ WS. '~4 <br /> <br /> SiTE NUMBER: ~4-8~488 <br /> <br />LOT; [BLOOK: SECTION: ! TOWNSHIP: ~ RANGE'. [ ZONE: MAP: <br />WIDTH: <br /> <br />TYPE: BUILDING <br /> <br />PERMil, OR APPLICATION ND: <br /> <br />PI.AN REViE:W <br />);;(U P..b [I,~I; STAf'E SURCHAR(:;E <br />/ON];Nr; SURCHARGE <br /> <br />90f~7804 <br /> <br />PHONE: <br /> <br />TO.T_AL ASSE¢~SED FEES <br />PR~4~: OL!S RECEIPTS <br />TI-B: S RECEIPT <br /> <br />BAL.AN(~:E 1' dE <br /> <br />QUAI,I'f']: TY <br /> <br />$36,, 7S <br /> <br />$98.89 <br />$98,, <br /> <br />* TEllS IS NOT A PERMIT. THIS APPLICATION MUST GO THROUGH A REVIEW PROCESS WHERE THE <br />FOLLOWIMG MUST BE COMPLffTE~). IT ZS THE RE8POMSIBILITY OF THE APPLICANT TO ASSURE THAT <br /> LI_. NECESSARY Ii,FORMATION HAS BEEN PROVIDEB. <br /> <br />HEIGHT:, 9 SETBAC,KS: FR <br />1-OTAL: SQ <br /> PL.AN. ACTION: ~ <br /> <br />OFFICE COPY <br /> <br /> <br />