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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, QBEGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 586-7904 <br /> <br />I am performing Wo¢kon a proper y own or' occupy <br />I am a r'egi¢tered builder OCr the authorized repfesen ave <br /> of a registered builder, <br />The work will be performed by a registered builder. <br />Other <br />[ have read and agree to the terms stated on the reverse side of <br />this document. <br /> <br />SIGNATURE OF APPLICANT: <br /> DATE: <br /> <br />ow~:TE; 0?/25/90 ¥iM£~i0:0g:2g <br /> <br />TAX LOT: <br /> <br />S~TUS ADSRESI~'~OFT' VER, N <br /> <br />USE OF BUILDING'. <br /> <br />CONSTRUCTION TYPE: <br /> <br /> CON'C~ACT CI~Y: UGB: <br /> NE <br />OR 97002 <br /> ~ARZeN ~'rY NO <br /> <br />CATEGORY; <br /> <br />OOCUPANDY: RESIDENTIAL <br /> <br />OCCUPANT LOAD: <br /> <br />NO OF EEDH00M5 <br /> <br />MAILING ADDRESS: <br /> <br />' <br /> <br />PRESTIGE NH SERVICE <br />8660 ~ CHEROKEE S'I' <br />F~40N E: 692-4256 <br /> ~L(DCK: <br /> <br /> CENTURYMEADO~S <br />97082 <br />')'UAL&TIN,OR <br /> SiTE NUFE~ER: 10354 <br />'SECTIO,; !~8¢~RiP; :~AN~LUATzON: ZONE: <br /> <br />MAP: <br /> <br />SF NO. N9 ..... <br /> <br />TYPE: ELECTRICAL <br /> <br />CONTRACTOR, NO. <br />LICENSE NO: <br />GRDFI', VEEN <br />PRES'r.[GE NH SERVICE <br />8660 ~ CI"IEROKEE ST <br />PHONE: 692-~256 <br /> <br />PEf,~I'r OR APPLICATION NO: 25896 <br /> <br /> ,!~JPERVISING ELECTRiCIAN/NUI~JER <br /> <br />97062 <br />TUALATIN,O <br /> <br /> iT~ <br />MOBILE HOME SPACE (eVC F..~,,'~iP) <br />f~CC:CiLE HOffiE CONNECT/ON <br />FLEET ~{JRCHARGE -ZONE 6 <br />ELECTRICAL STATE SURC~ARE~E <br /> <br />TO'rAL A~,~ESSEO FEES <br />PREVIOIJS RECEIPTS <br /> TH[8 RECEIPT <br /> <br />PAYEE: GROFT, VERN <br /> <br />QUANTITY AMOONT <br />1 $25.oo <br />1 $25,00 <br /> $7.68 <br /> $2.50 <br /> <br />$60.18 <br /> $o.oo <br />$60.~8 <br /> <br />BALANCE DUE $0.00 <br /> <br />' RECE[P'r NO: 2?424 <br /> <br /> RECEIVED BY: PR ................... ,4 ..................... TYPE: CA CHECK ~: <br /> x¢ THiS 18 A VALID PER~II'r ,ll'li8 PEI~iIT 18o DA'Y~ FROM ITS ISSUE DATE. IF <br />CONSTRUCTION ~ I~OR A PERIOD OF 180 DAY~, OR IF CONSTRUCTION FAJ[i_~ TO ~EET ALL <br />~HALL EIE[A~E <br /> <br />REMARKS: MN SERV &OC~N R2¢2683 , y~~~ <br />DONALD E. AOODLEY, f~ARiON COUNTY BuILD,XN~ OFFICIAL / B .................................. <br /> <br /> OFFICECOPY <br />FORM # MC 15-56 REV, 4/90 <br /> <br /> <br />