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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 H~GH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE; 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 58,8-7904 <br /> <br />I am ¢erformin~ WOrk on a property ~ own or occupy <br /> <br />SIGNATURE OF APPLICANT; <br /> DATE: <br /> <br />OWNER: <br /> £)AJ E= 12/11,/9'1 T.~ME; 8.-01.,54 <br /> <br />TAX LOT: <br /> <br />OATEGORY: <br /> <br />OCCUPANCY: <br /> <br />RESiDENT.~AL <br /> <br /> 355 EVE~REEN OR <br />uS~ &M~L~f~C~-E OR97325 <br /> <br />MAILrNC ADDRESS: <br /> <br />MANUFACTURED STRUCTURE <br /> <br />36457 5. 5ANf'ELL <br />rCDLALLA <br /> <br />: CONTRACT CITY: UGB: <br /> <br />OCCUPANT <br /> <br />AURSV1LLE <br /> <br />NO <br /> <br />EVERGREEN MOBibE ES'T'A'1ES <br /> <br />Si'T2E NUMBER;:. 14707 <br />~ANC'~ALUA'I' 1ON: ~o~tE; MAP: <br /> <br />25 8S 2W R~ <br /> <br />FYPE: MANUF'ACf'UREO S'I'RUC'T'URE <br /> <br />CON'f RAC'[OR, NO. <br />~I MPSON, GR~G <br />3645? S. SAINfELL ~9 <br />I~OLAL, LA <br />~¢3NE: 829"~5290 <br /> <br />PERf4iI' OR APPLICATION NO: <br /> <br />~AANU~'.AC;'LJRE0 S'f'N:UC'f'URE PLACP_J~,IEN'F/C'ONNEC'I'.~ON <br />~.1ANUFAr,;;(UREO S'I'RUC'I'URE STATE FE6 <br />MANUFACIURE0:5'f'RUC'f'URE STATE ~:~JRCHARGE <br /> <br />TOTAL A,5,SESSED FEES <br />PREWIOU$ REC~IP'r$ <br />'1'HI$ RECEIP"I' <br /> <br />903732? <br /> <br />AMOUNT <br /> $182.~0 <br /> $20.00 <br /> $9.!0 <br /> <br />$21t,10 <br /> $o.oo <br /> <br />BALANCE DUE <br /> <br />PAYEE: SIMPSON, 6REG iNVOiCE 39293 <br />RECEIVED BY: PB ............................................................................................... TYPE: iN CHECK ~: <br /> <br />~ THiS iS NOT A PER'lIT. THiS APPLICATION IvlIJST 60 THROU6EI ARE"VIE~ PROO~ ~-IERE THE FOLL~iN~ <br />~ST BE ~PLETEO. iT iS THE R~SIBILITY OF THE APPLI~T TO ~RE THAT ALL NECE~ <br />iN~O~TI~ H~BE~ P~VIDEO. <br /> <br />5EP'IIC: BY ............................................. DATE ............................................. <br /> <br />ZONING: ~Y DATE SETBACKS: <br />REMARKS: NOB]'EE""~O~E PLACERE~T ........... <br /> <br />PLANNING AC'I'tON: <br /> <br /> CiTY JURiSDIC'I'iON: BY ............... DA't~ <br />FR.............~-~ LS ................. R~ ....... RR ............. SP ....... <br /> <br />OFFICECOPY <br /> <br /> <br />