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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 am performing work on a property ~ own or occupy. <br />lam ~ registered builder OR ( ) the authorized representative <br />of 8 reRistered builder, <br />The work will be gerforrfted by a registered builder. <br />Other ....... <br />I 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~'fE: 12/19/91 TIME: 13:24:41 <br /> <br /> 0E'f'ROI']' LAKE STATE PARK <br /> <br />TAX LOT: <br /> <br />CONSTRUCTION TYPE: <br /> <br />CATEGORY: <br /> <br />OCCUPANCY: <br /> <br /> NORTH ~AJN'fiAM HWY <br /> OE'I ROI T OR <br /> <br />USE OF BLJILDING: <br /> <br />CONTRACT CITY: UGS: <br />IV'~R.[C:.:.:.:.:.:.:.:.:.~N COUNTY NO <br /> <br />PO BOX 54,9 <br />DE ['ROi f 9)'34.2 <br />I)HON~; <br /> <br /> Si'I'E NUMBER: <br />...... VALUA'f'~ON: <br /> SECTION: TOWNSHIP; RANGE: ' ZONE: <br /> <br />, ' ...... 10 .... 70 5E <br />;DEPTH; : AREA'. UNITS: IRREG. LOT: CORNER: <br /> <br />15185 <br /> <br />NO: NQ <br /> <br />COMMERC i AL(, <br /> <br />NO OF BEOR00MS <br /> <br />MAP: <br /> <br />'f'YPE~. ELECTRICAL <br /> <br />CON'f'RACTOR, NO_ $1702 <br />LICENSE NO: <br /> <br />2'2.50 Judson SE <br />Sa"lem, 97302-0f3BO <br />F"HONE: 364-0?70 <br /> <br />PE&I'4.I'F OR APPLJ. CAT.[ON NO: 3?4?? <br /> <br /> SUPERVISING ELEC'1'R I C I AN/NUMB [~iR <br /> <br /> l 'F Er4 <br />BRANCH CfRCLIi'f'~, - TNO TO TEN <br />ELECTRICAL STATE SURCHARGE <br /> <br />QUANTITY <br /> 1 <br /> <br /> A~0UNT <br /> <br /> $2_50 <br /> <br /> 'f'OTAL ASSE~ED ~EE~ $52-5(] <br /> RREViOUS RECEIPI'8 <br /> 'f'Hi8 RECEIP'f' $52.50 <br /> BALANCE ~.lE $0.00 <br /> PAYEE: Mason E"lect¢fic RECE~Pf' NO: 39445 <br /> RECEIVED BY: DM2 TYPE: CK CHECK ~: 2059 <br />*TH[S iS A VALID PERI~IiT · THiS PER~iT EXPIRES 180 DAYS FROM ['rs I~E OATE. iF <br />CONSTRUCTION CEJ~ FOR A PERIOD OF 18D DAYS, OR IR CONSTRUCTION FAILS 'fO MEET ALL <br />REOt. JIRE~4TS OF STATE ~ AND f~R[ON COUNTY BUILDING AND ZONING ORD[NANCES, THZS PER~llT <br />SHALL BBCOME NULL AND <br /> <br />REMARKS: 2 CiR/RES'f'~ <br /> <br />OONALD E- W~DLEY, MARION COUNTY BUILDING OFFICIAL / BY <br /> <br />OFFICE COPY <br /> <br /> <br />