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220 HIGH STREET NE <br />SALEM, OREGON 97¢O1 <br /> <br /> PHONE:588-5147 ~;00- 4':30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am a registered buitder OR ( ) the authorized representative <br />o a eg s e ed builder, <br />The work wilt be performed by a registered builder, <br />Other <br /> <br />OWNER ~ I <br />, NILNE~, PATRiCiA ! 40238-000 ~ <br />:: $1TU~ ADDRESS: i OONSTRUOTION TYPE; : OCCUPANCY: <br /> <br /> 10268 CHAMROEG RD NE ~-EO-~'-~'~[~-~'. IoE~UPA~ L0^D: <br /> <br />AURORA <br /> <br /> OR 9?002 I , J <br />............................ ~ARLON Or~NIY.:i NO ~ <br /> <br />~N0 OF 8EDROOM$: <br /> <br />10307 f~AI'THiEU LANE NE <br />AURORA OR 9?002 <br />PHONE.* <br /> <br />SITE NUtflBER: 92-02101 <br /> VAL,UATION~ <br /> <br />RESI DE1N 1' I:'~ <br /> <br /> TYPE: ELECTRICAL PERf41T OR APPLICATION NO: 9040387 <br /> <br /> CONTRACTOR, NO. 06281 8UPERVf$iNG ELEC'rRICIAN/NUD,1BER <br /> LICENSE NO: <br /> N~l"ltam K Enge"lman <br /> PO Box 451 <br /> Hubbard, 9?092-0000 <br /> PHONE= 981-8041 <br /> <br /> ¢4ANUFACTUREO HOME SERVICE/FEEDER 1 $40.00 <br /> ELECTRICAL STATE SURCHARGE $2.00 <br /> <br /> TOTAL AS~EE~ED 'FEE'~ $42. .00 <br /> PREVIOUS RECEiPT$ $0. O0 <br /> THIS RECEIPT $0.00 <br /> <br /> BALANCE ~UE $42.00 <br /> <br /> o~v~¢;. . RECEI Pt NO: <br /> RECEIVED BYt ~ . : 'TYPE:, CHECK ~. 0 <br /> <br />~ THIS [~ NOT A PEI~ltT. ~FI[S A REV[EN PI~BCES~ ~rlERE THE <br />I=O~LDI~;[N6 I~IUST= BE C~LETED.:; ~[; ;[$i~HE ::REE~oONS[BZL[~FY:OF~ THE APPL[CANT TO A~7~URE THAT <br />ALL NECE~RY INFO~TION PROVIDED. <br /> <br />PLAN REVIEW.* BY DATE CiTY juRisDiCTION: BY OAI'E <br />REJ~AR~: f~H SERVICE <br /> <br /> OFFICE COPY <br />FORM # MC 16-6s REV, 4/90 <br /> <br /> <br />