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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO, 225 <br />220 HIGH STREET NE <br /> BALI=M, 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 representative BfGN^TURE OF APPL CANT <br />of a registered builder. <br />The work will be performed bye registered builder, <br /> <br />I have read and agree to the terms stated on the reverse 8ids of · <br />this document. DATE <br /> <br /> MILL CREEK IiSTATE?J <br />BOX 278 <br />DA:~ ~ ' '( 9703: qTT~ ~II~D~. o~ ~ <br /> <br />PERMIT OR APPLICATION <br /> <br /> 1 TEN <br />BUl L.I) :),'NG FEi.:. <br />~;;' ]..i A ~I REVIEW <br />ZOHIN6 SURCHARG;E <br /> <br /> 68761 <br /> <br />ARCH I TEC;T/rZNG ? HEER,¢ <br /> <br />F I JONI= ,, <br /> <br />EHERGY PATE: <br /> <br /> OFFICE COPY <br />~ORM # MC 15-§8 REV. 4/~0 <br /> <br /> <br />