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MARION COUNTY BUILDING INSPECTION <br />S~:NATOR 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 a registered builder O~ the authorized represen a ye SIGNATgRE O~ APPLIO <br /> <br /> The work wil{ be performed by a registered builder. <br /> Other <br /> I have read and agree to the term8 8tared on the reverse side of DATE: <br /> <br /> DdTE: 09/14/92 ~.Z~E; ~: <br /> KLEIN, LARRY 56401000 : RESIDENTIAL <br /> <br /> ~784 H~LL CREEK RO SE j~ ................ CONT~AOT CITY: ~0~: ~OCCU~ANT LQA~: <br /> flUMSVILLE OR 97~25 ,MARION COUNTY', NO <br /> <br />, MANUFACTURED STRUCTURE <br /> 2 <br /> <br /> 9804 HILL OREEK RD SE ~7 ~ ....................... <br /> AUHSWLLE. OR ~ -- r ~If[ HUMBER: <br /> PHONE: 74~-2405 i VALUATION: <br /> <br /> '.o <br /> <br /> TYPE: MANUFACTURED STRUCTURE PERHIT OR APPLICATION NO: 9042505 <br /> CONTRACTOR, NO. <br /> KLEIN, LARRY <br /> 9804 HELL CREEK RO SE <br /> ~UHSVILLE.~ OR <br /> PHONE: 74~-2405 <br /> <br /> ITEH QU~NTITY ~HOUNT <br /> MANUFACTURED STRUCTURE PLACEMENT/CONNECTiON <br /> N~NUF~CTURED STRUCTURE STRTE FEE $20.00 <br /> MANUFACTURED STRUCTURE STATE SURCHARGE $9.10 <br /> MANUFACTURE~ STRUCTURE ZONING SURCHARGE $~5. <br /> TOTAL ASSESSED FEES $226.10 <br /> ' :: PREVIOUS RECEIPTS <br /> :' ~HI~ RE~EIP~ · , $226,10 <br /> <br /> oD <br /> PAYEE: KLEIn, LARRY : RECEIPT. 44575 <br /> <br /> F~LOWIN~ M~ST BE CQM~EETED~ : If I~'~::' RE~NSIBIkI[Y'QF THE APPLICANT TO <br /> THAT ALL NECESSAEY INFORHA[ION HAS B~EN PROVIDED. <br /> <br />PLAN REVIEW: 8Y '"~('/ DATE <br />CITY JURISDICTION: BY ........ DATE <br /> <br />SETBACKS: FR ~ e <br /> ns_i~Z <br /> <br />FOnM # MC 15-56 R~W, 4¢~0 OFFICE COPY <br /> <br /> <br />