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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALBM, 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~regsteted builderOA( )thoauthorizedrepresentglbve <br />Of 8 registered buNder. <br />The work will b8 performed by a registered builder. <br /> <br />I have read and a9ree to the term8 8tsted DA tho reverse 8ide of <br />tl~$ dooument. <br /> <br />SIGNATURE OF ARRLICANf: <br /> DATE; <br /> <br />OwNS{E: '/O/28/91 <br /> <br /> EVERGREEN <br />, SITUS ADD~ESS~ <br /> <br />i'I~E: t5;5'7:13 <br /> <br />CON$TRMCT~ON TYPE: <br /> <br /> 240 YEW <br />AU~V i LLE <br /> <br /> CON~RAO~ CITY: : 0~g; <br /> <br />OR 973~5 <br /> AU~ViEL~ NO <br /> <br /> R~SL DEN ~ IA~/ <br />OCCUPANCY; <br /> <br />OCCdPAN'I LOAD: <br /> <br /> PH ON E:; <br /> <br />LOT: <br /> <br /> SITE NUMBER; <br /> VALUA'I: iON: <br />BkOOK: , §¢,~TIO~i ToWN~I411~ RANGE; <br /> <br />iDEPTH; AfREA: UNITS: <br /> <br />14790 <br /> <br />, IFI~EG. LOT: 0ORN~n: <br /> NO NO <br /> <br />MAP: <br /> <br />TYPE: ELECTRICAL <br /> <br />CONTRACTOR, NO. 2?459 <br />LICENSE NO: <br /> R & R B"lertnffc ln¢ <br />Po 8ox 52 <br />'¥'unne~, 9'7392~0000 <br />PHONE: 743~2546 <br /> <br />PERMIT OR APPLICATION NO.' 364]4, <br /> <br /> SUP_RV U51NG ELECTRiCIAN/NUMBER <br /> <br /> ITEM <br />ADDITIONAL FEES <br />ELECTRICAL S'T'A"t'E SURCHARGE <br /> <br />PAYEE: <br /> <br />QLIAN 7'I FY AMCUN ¥' <br /> $30,00 <br /> <br />TOTAL ~ES~ED FEES <br />PREVIOUS RBCEIP']'S <br />THIS RECEIPT <br /> <br />ii, ,LANCE DUE <br /> <br />RECEIPT NO: <br /> <br />$31.5O <br /> $,0. O0 <br />$3~ <br /> <br />3834.5 <br /> <br /> RECEiVBD BY: CL ........................................................................................................................... TYPB: CK CHECK ~: 9990 <br /> <br />* ~HZ5 iS A VALID PEl~llI ~ THiS PERMIT EXPiRE~3 180 ~Y8 F~ ITS lSg ~TE. <br />~ST~CT[~ C~ ~R A PERIOD OF 180 ~YS, OR IF ~ST~CTI~ PAI~ TO ~T ALL <br />~IR~TS OF STATE ~ ~D ~RI~ ~NTY 8UI~ING ~D Z~ING ORDIN~C~. THIS <br />~ALL B~E NULL ~O VOID. <br /> <br />REMARKS: MP'G $VC R~3030 <br /> fAA <br />OONALO ,P,., NOODLEY, MARION CQUNTY BUILDING OFFiCiAL / BY ................ ~ ........................................................ <br /> <br /> <br />