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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97801 <br /> <br /> PHONE 588-5147 <br />CODE-A-PHONE 4:30 P.M. - 8:00 A.M. <br /> <br /> I am performing work on a progerty I own or occupy. <br /> lamarogisteredbuilderOR{ )theauthorizedregresentatwe <br /> of 8 registered builder, <br /> The work will be performed by a registered builder, <br /> Other_ <br /> I have read and agree to the term8 stated on the reverse side of <br /> this document. <br /> DATE: 12/17/87 TIME: 9:17:54a <br /> <br />OWNER: BUTLER, GEORGE L. & EDNA t4. ifAXco¥1 <br /> <br /> SITUS At~DRE,~S: i ~STRUOTION TYPE: <br /> <br />~ 0~0U ~ANCY: <br /> <br /> 8721 LITTLE RD <br />~UMSVILLE <br /> <br />11459 STAYTON RD SE <br />STAYTON, OR 0758~ <br />PHONE: 769-5503 <br /> <br />LOT: SLOCK: <br /> <br /> ~-88~f &~'¢ 6'~'; ! OCCUPANt LO^O; <br />OR 973 6 RIm i [ <br /> NO O~ BEDROOMS <br /> <br />SITE NUNBER: 3033 <br />VALUATION: <br /> <br />TYPE: ELECTRICAL PERMIT OR APPLICATION NO~ 5967 <br /> <br />CONTRACTOR, NO. 4354 SUPERVISING ELECTRICIAN/NUI~ER <br />LICENSE NO: <br />ROY TODD ELECTRIC <br />PO 80X 4 <br />SUBLIMITY, O~EGON 97385 <br />PHONE: 769-2282 <br /> <br /> I TEN QUANT I TY AI'4OUNT <br />MOBILE HOME SPACE (SVC EQUIP) <br />r4OBILE HOME CONNECTION 1 $20.00 <br />FLEET SURCHAF~E -ZONE 3 $3.84 <br />ELECTRICAL STATE SURCHAI~E $2+00 <br /> <br /> rfOTAL <br /> ;.::::.. 15"~EV:~OUS::!REOE:i'pTS $0.00 <br /> ,, RECEIPT: $45~ 84 <br /> ', : BA£ANCE DOE $0.00 <br /> <br />PAYEE: ROY TODD ELECTRIC ' RECEIPT NO: 6545 <br />RECEIVED BY: JB ....... _.__~_= .... , : : ',,, . , - .... TYPE: CK: CHECK ~: 1216 <br /> <br />OODI~'i"RiICTION CF_A~B FO~ A;PCi~RlrOD, O~'1 FAIL~ TO <br />R~OUI~ OF STATE ~ ~ ORDI~. THIS PER~IT <br />S~CZJL BECZ~E <br /> NULL AND VOIO. <br /> <br />REMARK. S: CONN/SERV 1~6505 ROY TODD ELEC <br /> <br />fORM, ~C ~.~6 R~V 6/,~ OFFICE COPY <br /> <br /> <br />