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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:588-5147 8:00- 4:80 <br />24 HOUR CODE-A-PHONE: 588-7904 ,¢5~¢.~(~ <br />I am performing work on a grogerty I own or occupy. <br />I ~m a registere¢ builder OR the authorized regresentative S~GNATURE Of APPLICANT: <br />of a registered builder. <br />The Work win be perfformed by a registered builder· <br />Other <br />~ have read and agree to the terms stated on the reverse side of DATE: <br />this document· <br /> <br />05/0?/92 'tIME: 11:17.:29 <br /> <br />~RiS'FOL, HARLEY <br /> <br />, TAX LOT: !CATEGORY1 <br />CONSTRUCTION TYPE: :OCCUPANCY: <br /> <br />RES i DEN 1' 1 A <br /> <br /> 11848 DUCK INN ROAD <br />GERVAIS OR <br /> <br />97026 <br /> <br />~, MARiON COUNTY [ NO <br /> <br />MAILING ADDRESS; <br /> <br /> PHONE: 792-4738 <br /> <br />WIDTH: DEPTH: <br /> <br /> VALUAT i ON: <br />· ;SECTION: : fOW~NIP: ~A~GE: ~, 7ONE: <br /> <br /> ~REA: ' UNITg; IRREG, LOT; CORNER: <br /> O. , NO NO <br /> <br />MAP: <br /> <br />TYPE: ELECTRICAL <br /> <br />CONTRACTOR, NO. <br />LICENSE NO: <br />BRISTOL, HARLE~ <br /> <br />PERI'4I¥' OR APPLiCATiON NO: 39835 <br /> <br /> SUPERVISING ELECTRICIAN/NUME~ER <br /> <br />PHONE: 792-4738 <br /> <br /> i'TEM <br />SERVICE/FEEDeR LE~ THAN 200 ,aC,lF~ <br />8RANO~ CIRCUIT, WITH SERVICE: ORFEEDER <br />ELECTRICAL STATE fJURCHARGE <br /> <br />QUANf'i'I'Y AIgKOUN[ <br />1 $5o.00 <br />6 $12_00 <br /> $3.10 <br /> <br />PAYEEs BRISTOL, HARLEY,,: <br />RECEIVED BY; BM2 , :' <br /> <br />TOTALASa~ED: FEES <br />PREVIOUS RECEIPTS <br />THiS RECEIPT <br /> <br />$65.10 <br /> $o.oo' <br />$65.10 <br /> <br />BALANCE DUE $0.00 <br /> <br />RECEIP'¥' NO: 41876 <br />TYPE: CK C~ECK ~; 0 <br /> <br /> STRIS IS A VALID PERMI:T~:),THIS PEI~IiT::EXpIRES 180 DAY~ ERO~ UTS I~E ~TE. IF <br />~ST~CTI~ C~ FOR;A,PERiOB,~:180 ~. ~ IF ~ST~CTI~ FAi~ TO MEET ALL <br />~I~ OF ~TATE ~ ~0 ~RI~ ~NTY BUILDIN~ ~D Z~iNG ORDiN~C~, THi~ PE~IT <br /> L 8~ NULL ~D~iO;, . <br /> <br />RESc'tARKS: 200 A/6 CiR E,,'XlSTiNG FAf'~lBLDG <br /> <br />[X)NALD E. INOOOLEY. MARION COUNTY BUILDIN6 OFFICIAL / BY <br /> <br />OFFICE COPY <br /> <br /> <br />