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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 - 4:30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />The work will be performed by a registered builder. <br />Other <br /> <br />have read and agree to the terms stated on the reverse side of <br />this document. <br /> <br />SIGNATURE OF APPLICANT: <br /> DATEI <br /> <br />bw~rE: 10/82/90 T[.~IE: ~0=t4:0'! i TAx LOT: <br /> <br />: MILLER, JERRY <br />i StTDS ADDRESS: , CONS%RUC%ION TYPE: <br /> <br /> AU~VI LLE OR 97325 m ~ <br /> ~s~ o~ ~u~L~N~; ~R~ '~N:F~ NO <br /> <br />CATEGORY: <br /> RES/DEN'I' 1AL <br />OCCUPANCY: <br /> <br />OCCUPANT LO~A~:~ <br /> <br />MAILING ADDRESS: STRUC'rURES OTHER 'FR~ BUIILD',[N~S su6ui~lSlON: <br /> <br /> 495 N. fflACY $'f ! ................................ "~ <br /> I~..h'4iNNViLLE, OR 97128 i <br /> F>HONE: 472-781lB I SiTE NU~ER: <br /> t 11o75 / <br /> <br />WIOIH: DEPTH: ? A~'~:~,i :'13 ! UNICA: IDS iRREG LOT: <br /> ~oo ]~e..J ~ SF NO NO <br /> <br />49 <br /> <br />I'YPE: BUiLDiNG PEr-~I'I' OR APPLICATION NO*. <br /> <br />CONTRACTOR, NO. <br />~1i LLER, JERRY <br />435 N. HAOY ST <br />rc~INNVILLE, OR 97128 <br />PHONE: 472-7618 <br /> <br /> 26lB62 <br /> <br />AI;~JHi TFJC'r/ENGiNEER, NO. <br /> <br /> iT~ <br />BUILDING FEE <br />PL,N~I REVIEN <br />FLEET SURCHARGE ~ZONE 2 <br />BUILDING STATE SURCHARGE <br />ZONING SURCHARGE <br /> <br />PAYEEt HILLER, JERRY <br /> <br /> QUANTITY <br /> <br />TO'TALA_%.~EE~SED FEP.~ <br />PRE~/IOUS RECEIPTS <br />THIS RECEIPT <br /> <br />BAL~t~NCE DUE <br /> <br />RECEIVEO BY: ct' ...................................................................... TYPE: RF CHECK <br />THIS tS NOT A PERNi'r - THIS is A REPUND [XSOJf4ENT. <br /> <br /> $O.Oo <br /> <br /> $o.o9 <br /> $o.6o <br /> <br /> $2.50 <br /> <br /> -$20+12 <br /> <br /> $o.oo <br /> <br />29259 <br /> 0 <br /> <br />REl~RKS: REFUND OF UN-ISSUED APPLICATION <br /> <br />HEIGHT: TOTAL ~ FT: <br /> <br />S'FORI E~5: <br /> <br />PL~. AC T I ON: <br /> <br /> OFFICE COPY <br />FORM # MC 1 E-58 REV. 4/90 <br /> <br /> <br />