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MARION COUNTY BUILDING INSPECTION <br />SENATORBLDG 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 />am performing ¢~ork on a property I own or occupy <br /> <br /> I have read and agree to the terms stated on the reverse side of <br /> th~s doc:ument <br /> <br /> DALE: 04/08/91 lJ,~; 12:08:29 <br />OWNER <br /> HOLOUt~EK, ~ERT <br /> <br />90221-150 <br /> <br />OCCUPANC~ <br /> <br />RESI ObN 1 JAL <br /> <br /> 200 .!:~J'qI-IAM AVE <br />DEIROIf OR 97342 <br /> <br />USE OF BUILDING <br /> <br />CONTRACT CITY UGB <br />DEl ROI T NO <br /> <br />OCCUPANT LOAD <br /> <br />MAILING ADDRESS <br /> <br />2150 34FH AVE NE <br />:SALEM, OR 97303 <br />PHONE: 363-55?8 <br /> <br />LOT BI. QC'K SECTION 'f OWNSH IP <br /> 11 9 2 10 <br /> <br /> 50 150 YEOO- SF <br /> <br />SUBDIVISION <br /> HA~C4OND <br /> <br /> SiT~ NUI'4BER: 126?4 <br /> VALUA F iON: <br /> <br />RANGE ~ ZONE <br />5g <br /> <br />IRREG LOT CORNER <br /> NO NO <br /> <br />[YPE: MEONANiCAL PERNi'¥' OR APPLICAFION NO: <br /> <br />CONIRACfOR, NO. 5't'i'04 <br />MEL'S S rOVES <br />908 EDGENAfER NW <br />,~ALP_.~I, OR 97304, <br />PHONE; 3'78~'01~2 <br /> <br /> irEM <br />DOMESTIC I~,~,DD SFOVE <br />D4ECHANICAL BASE FEF- <br />IVIEOHANiCAL STATE SURCHARGE <br /> <br />PAYEE: HOLOUBEK, K',U~- R f <br /> <br />9031399 <br /> <br />TO1AL ,~¢EE~£D FEbS <br />PREVIOUS RECEIPTS <br />THIS RECEIPT <br /> <br />C~ANTi'fY A~OUN] <br /> $?.5~ <br /> <br /> $0_88 <br /> <br />$18.28 <br /> $0.09 <br />$18_38 <br /> <br />BALANCE 0UE $0.00 <br /> <br />INVOICE NO: 33160 <br /> <br />* THiS IS NOT A PEI~ilT, THIS APPLICATION NIUST (~0 THROJ(~i A REVIEW PROCEE~ tAHERE THE <br />FOLLOWING IvIUST BE CI~IPLETEO. iT IS THE RE~I:~NSIBiLiTY OF THE APPLICANT TO A,.,%.,,~AJRE THAT <br />ALL NEC~RY INFORMATION HA.~BEEN PROVlOEO. <br /> <br />PLAN RE¥1EN.* BY <br /> <br />REfC, ARK~: WOO~'l OVE <br /> <br />CiTY JURISDICTION t 8Y OAfE <br /> <br />FORM # MC 1,5-,56 REV 4"90 OFFICE COPY <br /> <br /> <br />