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MA. RIO~ COUNTY BUILDING INSPECTION <br /> <br />SITE EVALUATION ANDIOR gEFYiC pERMIT A~PLICATiON <br /> <br /> Gay Waler W~M~ Di~O~I ~mO 1~-~ lO.fl0 <br /> <br /> , ~-~ <br /> Ste¢ glo 2~.00 <br /> <br /> ~0o ~ o_~s~,<~oo{ ~:,vs~ l~.oo ,, '.~ ..... <br /> {For ~sc~ ~ditio~al $O~al, <br /> <br /> ~. Ml,o~ ,,.. ,.~,~ ~0.~ <br /> <br /> F~ialng Sy~m Bv~g~Oo ~u 150.~ '"10.~ ........ <br /> A~o~ign N~c,~tcld ~t) 1 ~ 10.00 <br /> <br /> Annul Eqalu~o~ ~fA~mfive ay~m 150:~ .,10~ , <br />'~A0nual ~al~on of~e ~m, ~.00 10.~ <br />Pum~=( ~k laa~6on, ea., ~dl. ~ok ~$ ~ .00 <br />~ber <br /> <br />) l will c~l when To~ Holo$ ~g <br /> <br />am pc rt+o."mln8 v.~ork <br /> <br /> work will b~ pcrforme, d by <br /> <br />of tim ~ of Ore~o~ trod t~e ordlnane~s Of ~011 County. <br /> <br />NAME OF A.PPLiCAN'~ (please print): <br /> <br />3~;~ OF ~I.~ANT, "' D~TE. <br /> <br />MC 15-SI REV 2/93 <br /> <br /> <br />