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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO. 225 <br />220 HIGH STRGET NE <br /> SALEM, OREGON 9'7301 <br /> <br /> PHONE: 588-514.7 8:00 - 4:30 ~ .... J ~? <br /> <br />I am performi.g work o~ a property I ow. or occupy. /~' ~~~ <br />Ioama ~[pstere. ~ oer-a?Rister'e9[,bu'il~er OR the authorized rep,esentative SIGNATURE OF APPLICANTL/--__' .~// ~ ...... <br />TheotherWOrk will be pe rfor't~ed by 8 registered builder, ~/~/¢ / /¢/ <br />I havo read and agree to the terms stated on the reverse sid~ of OATE~ <br /> <br />°w~[9~-f'E; 04/03/91 <br /> <br />11:28:52 <br /> <br />CONSTRUCTION TYPE. OCCUPANCY. RE'S I [..TEN 'i' I At <br /> <br /> CONTRAS f OITY. UGI] <br /> <br />USE <br /> MARION r,.,,',',',',',','O ~ N 1 ' Y NO <br /> <br />~ i LE <br /> <br />,SITE NUfI~ER: 126~9 <br />R^NC]~F,,ALUAT ION: zoN~ <br /> <br />3 <br /> <br />TYPE: MOBILE HO~E PE~'~IlT OR APPLiCA'rlON NO: <br /> <br />r...'r,~NTf. LACTOR. NO. 4907 <br />KILROY$ r, IOalLE HOC4E <br />22:30 NO PACIFIC H~ <br />~U~, ORE~ gT0'l 1 <br />~E: 371'-6820 <br /> <br /> 1 'fE~ <br />I~OBILE HOf4E B.-~:~E FEE <br />/~.JBiL£ HONE STATE FEE <br />/t'lGalLE HOME ZONING SURCHARGE <br />t4C~ILE HONE STATE ~JRCt-IARGE <br /> <br />9031311 <br /> <br />T.OTAL. AS~E...~ED FE6.S <br /> <br />QUANT 1 I'Y <br /> <br />15. 15 <br />$5.25 <br /> <br />$115.50 <br /> <br /> , PRE¥iOXJ¢¢ RECEIPTS $0.00 <br /> ; :TH I~5 RF'"'CEI PT .' $115.50 <br /> ~ BA~O~ ~E $o_oo <br /> <br /> P~E; NE~, c~16' ~ RECEiP'r 32~66 <br /> RECEIVED BY: ~2 .... ~ : TYPE: OK C~ECK ~: ~58 <br /> <br /> * TH~ ]8 NOT A P[~ZT. TH~S A~LZ~T]~ ~aT ~ TH~ A R~Z~ P~ ~ THE <br />~L~IN8 ~8T 8E ~f~. l~ 18 THE ~Si81LITY OF THE APPLI~T TO ~ THAT <br />ALL N~ IN~O~TI~ <br /> <br />¢SEP'TIC: 8Y DATE CiTY JURISDICTION: BY ........................... DATE .................................. <br />ZONfN6..-. BY ~../..i~ DATE ~.~- ¢'i SETBACKS; FR_/o_..: ..... LS /2 m 3' . ................... <br />RE;I~IARKS: Iv~'i'"E'"'FIr.~E R~736~ ........................... ! .................... RR,,.._g..¢2....'.. SP <br /> <br />PLANNING <br /> <br />FORM # MS 15-56 REV. 4/90 OFFICE COPY <br /> <br /> <br />