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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 508%147 <br />CODE-A-PHONE 4:30 P.M. - 8:00 A,M, <br /> <br /> I am performirt9 work on a property I own or occupy, <br /> I am a reg{stered builder OR ( } the authoNzed representative SIGMA'CURE OF ^PPL~CANT; <br /> of a registered builder, <br /> The work will be gerlorrned by a registered builder, <br /> <br /> I have road and to the terms stated on the reverse side et <br /> this document. <br /> <br /> SHAW, <br /> SAM <br /> 58044-000 <br /> ] RESI DEN T l AL <br /> iS,TUS A~6RESS: CONSTRUCTION TYP~: <br /> <br /> 30173 KEENE L~E SE ', CONTRACT C rg: ~-'~'~[ <br /> AUMSVI LLE OR 97325 j <br /> <br />~ILING AODRES~: ...... <br /> <br />¢ 2915 HAMTHORNE <br /> SALEM 97303 <br /> g~ONE: 588-6889 <br /> <br /> SITE NUM, BER: ~ <br /> VALUAT l ON: <br />: SEC'qSP: ' .................................................................. <br /> TOWNSHIP'. ' RANGE; i¢ ZONE: i MAp <br /> 8. 88 _1.~ ! EEU .'4~ <br />: 33.0000 AC NO NO <br /> <br />TYPE: PLUMBING <br /> <br />PERMIT OR APPLICATION NO: <br /> <br />CONTRACTOR, NO. <br />SHAW, SAN <br />2915 HANTHOFC,iE <br />SALEM 97303 <br />PHONE: 588-6889 <br /> <br /> ITEM <br />MATER LINES, 1ST 100 FEET <br />MOBILE HOME SEWER AND MATER CONNECTION <br />FLEET SURCHARGE -ZONE 3 <br />PLUMBING STATE SURCHARGE <br /> <br />QUANTITY ,AMOUNT <br />I $20.00 <br />1 $25.00 <br /> $2.84 <br /> $2_25 <br /> <br />TOTAL:ASS~:FEES $51.09 <br />PREVIOUSRECEIPTS <br />THIS, RECEIPT $0-00 <br /> <br /> $0.00 <br /> <br /> PAYEE , , ,, <br /> ,-, ............. :;, ,; , RECEIPT NO; <br />....................... ~ ..... ':z~%==:::=~:,~ .... ~~-~=-~ :~:~.T~PE:,,:,'CHECK ~: <br /> ~ THIS IS A VALID PER~4IT ~: THIS T~ I~ nAT~ T~ <br /> RC~(~j~T~[gI~I~ ~EA~E~_[O~ ~ PERIOD OR':IF:>CON$-'"-Tj:~jO'--yI~Fii'~-To~i~i~.r ~LL <br /> <br />REMARKS: CONN NL R~¢4882 <br /> <br />~NALD E. WOOOL. EY, MARION COUNTY BUILDING OFFiCiAL / BY <br /> <br />~O"M ,~ MC ~-~ ~V e/8~ OFFICE COPY <br /> <br /> <br />