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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 /> I have read and agree to the terms stated on the reverse side of <br /> <br /> DALE: 04/08/91 fi~E: 12:08:18 <br /> <br />OWNER HOLOUBEK,RC~ERI <br /> <br />SIGNATURE OF APPLICANT <br /> DATE <br /> <br /> TAX LOT 90221-150 <br /> <br />CATEGORY <br /> <br />RESi DIsN f [ Al <br /> <br />SllUS ADDRESS <br /> <br /> 200 5ANriAM AVE <br />O~IRO~I OR 97342 <br /> <br /> MOBILE H Ol',1E <br /> <br />2150 341H AVE NE <br />5ALUM, OR 97303 <br />PHONE: 363-5578 <br /> <br />CONTRACT CITY UGB <br />OEI ROi ] NO <br /> <br />HAMMOND <br /> <br />5IlS NUMBER: <br /> VALUAiiON: <br /> <br />OCCUPANCY <br /> <br />OCCUPANT LOAD <br /> <br />12674 <br /> <br /> 11 9 2 10 5E <br />WIDTH 50DEPTH "~50 AREA 7500. UNITS SF IRREG LOT NO-- coRNEP~o.. <br /> <br />MAP <br /> <br />mILE HONE PERI~4I[ OR APPLiCAflON NO: 9031398 <br /> <br />CONfRACfOR, NO. <br />HOLOUBEK,ROSERf <br />2150 94fH AVE NE <br />5ALEN, OR 9?303 <br />PHONE= 383-5578 <br /> <br />NO~3iLE HONE SASE FEE <br /> <br />NO'ILS HONE 5TAIE ~51.JRCHARGE <br /> <br />PAYEE; HOLOUSEK,ROSERf <br /> <br />TOTAL ArC,~ES.~ED FEES <br />PREVIOUS RECEIPTS <br />THiS RECEIPt <br /> <br />QUANTIIY <br /> <br />AMOUNT <br /> 89.25 <br /> 15_75 <br /> $5.25 <br /> <br />$110.25 <br /> $0.00 <br />$110.25 <br /> <br />BALANCE CUE $0,00 <br /> <br />iNVOICE 33159 <br /> <br /> RECEIVED BY: PR ............................................................... 'tYPE: IN CHECK ~: 0 <br /> <br />* 'IHIS IS NOT A PERI,lIT. THiS APPLICATION ¢¢LIST 60 THROUGH A REViE~ PROCt~SSt~ERE THE <br />FOLLJO~iNG F&JST 8E COMPLETED. iT iS THE RESPONSiBILiTY OF THE APPLICANT TO ASSURE THA] <br />ALL NECESSARY iNFORmATiON HAS BE~ PROVIDED. <br /> <br /> 5EFT iC: <br /> BY <br /> <br /> ZONING: BY DAI'~ Sgf'SACKS: PR 20 L5,,5 RS..5 RR 5 SP <br /> REMARKS: <br /> <br />PLANNING ACflON: <br /> <br />FORM # MC lbS~ REV 4/90 OFFICE COPY <br /> <br /> <br />