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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-PHON'E: 588¢Z964 <br /> <br /> I am performing work on aproperty I own or occupy, ' <br /> I am a registered builder OR ( the authori:[ed representative SIGNATURE OF APPLfCANT; <br /> <br /> The work will be performed by a registered builder, <br /> Other <br /> I have read and agree to the terms stated on the reverse side of DATE; <br /> this document· <br /> <br />Z OWNER; ; TAX LOT; { ~A~EGORY <br /> <br /> AU~ OR g7002 <br /> USE OF BUILDING; ~NO 0~ 8/OROOMS: <br /> <br /> SINGLE' 'PAM[ L;.Y' 'DWEt.;L-tNG¢5 ....... i ~UB61~iS~i ............... <br />,:MAILING ADDRESS; <br /> <br />R~ i DEN 1' i A[ <br /> <br /> I~ONE: i ::SZTENOMBER:B2-010?5 <br /> ~ : VAL~ATiON~~ $38,400.00 <br />: LO~: ; BLOCK: SECTION: i TOWNSHIP; i RANGE: I ZONE; I 'MAP; <br /> <br /> 270 22~ 51830. i SF i NO YES <br /> <br />3 <br /> <br />CONTRACTOR, NO. 46473 <br />Oavid D mather <br />4475 S Ti:mbe~ l'ral"l Dr <br />~n, 97071-8709 <br />~E: 534-2490 <br /> <br />ARCHiTECT/ENGINEER, NO. <br /> <br /> I 'rEH <br />EfU i LDiN~ FEE <br />PLAN REVIEW <br />BUILDING STATE ECJRCHAR~E <br />ZONING ~LIRCHARGE <br /> <br />FjUA¢41'i TY <br /> <br />AI~NT <br /> $233.50 <br /> $151.78 <br /> $11.58 <br /> <br /> ' , ~ ~ $11.68 <br /> TOTAL A,..~ED FEES ~ ~_~ $408.64 <br /> .... <br /> PR,E~i~ RECEIPTS , ~ ; Y~,, ~ .$408.64 <br /> PAYEE: <br /> RECEIVED BY: ~ TYPE: ~ECK ~ 0 <br /> <br />~ST~CTi~ ~='~A ALL <br />REdIReCTS, OF STATE ~,~$~'~~;E~'~iN~ ORDIN~O~, THIS PE~iT <br />~ALL BEdE NULL ~O <br /> <br /> OFF CECOPY <br />FORM # MQ 15-5~ REV, 4/~ <br /> <br /> <br />