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MARION COUNTY BUILDING INSPECTION <br /> <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, OrogoP, 973(/t <br /> <br />BUILDING PERMIT APPLICATION <br /> <br /> [~OR CiTY U~ ONLY <br /> <br /> MARION C0tJN'l"f <br /> BUILDING INSPECTION <br /> <br />To house e~ectronk: eqmpment <br />cable ~elevision service <br />See exhibit "A" attached <br /> <br />COMPLETE ALL SECTIONS I THROUGH 4 <br />1, JOB DESCRIFI'iON <br /> <br />RE,gl DENTIAL <br /> <br /> ( ) Addition <br /> <br /> ( ) Accessory <br /> <br />) Reloeatiou <br />) Other <br /> <br />COMMERCIAL <br />( ) Addition (X) <br />( )Alteration ( )Sign <br />( ) Challge of Occupancy ( ) Other <br /> <br />OescriptionofWork Provide cable television service <br />E~vcty Pttth: [' No. Storles [ { NO, of ~ploy~a: ExiMing - N~w- <br /> <br />LOCATION OF iNSTALLATION <br /> <br /> h~p,.rOwn~,S{ayton .... .,,C°°perative'Teleph°ne I m,i;g^d,~ P O Box t¢~7_~ ,-~/~/ ~ho.~o,".,, (503),.,, 769-~121 <br />so~Aaa,~. 225 W. For[est Ave.., ~=x;,t.s~. ,~69~,5-000, e~st~t Patton Slreet <br /> ....... Detroil ' (/;,.c, .~:~',~,~ ,~,/~;z' <br /> <br /> SubdivisiOn Hammond ~ .. ~ot ~7 ~.. <br /> <br />s- ~,~o. iCB , Tow.s~i~ -' 10S ~.8. 5E , ~,,*Commercial' Map <br /> .... ~vat¢ Wall ( ) Spring <br />I Lot Wklth 5 5 ~t Depth 1 00 A~es r~g, ~t Com=r Community Wall ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING TIZlE WORK <br /> <br /> ~m*Gib Branch <br />~raingM~,~p 0 BOX #77 Stayton, OR 97383 ... '~ %'~ <br /> <br /> (5_~) 769-2121 <br /> <br />4. FEE SCIfftlEDULE <br />] A. VALUATION (g~e "Valuation Schedule" to determine valuation b~t <br /> <br />Valuation: <br /> <br />(3) P-~inspe~tion Fe~ (~ $25.00 <br /> <br />=$ <br /> <br />I h~reby cc~it~ that thru above information is correct, <br />Permits are non-transferrable and expiee if work is eot stat~ed wRb.[n 180 days of i~suatme or if work i~. sutpende<l for 180 day~. <br /> <br />NameofApplieant(EloasePrint); Stay:on Cooperative Telephone Company <br /> <br />Signature of Applic~t: ~Date: <br />MC I3,73 Rev 1/95 <br /> <br />(503) 76%2121 <br />September 29, 1995 <br /> <br /> <br />