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SENATOR BLDG. NO. 225 <br />220 HIGH STREET NI~ <br />SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A.PHONE: 588-7904 <br /> <br /> o a registered builder. <br /> The work will bo performed by a registered builder, <br /> Other <br /> <br />ADDRESS: CS~Obf~O~ ~V~: <br /> ..... ) CONZSArT CITY: ~ UGB; ~ OOOUPANT LOA~: <br /> <br /> :1. 2 J. :1. 40 t ~ AR [ 3 <br /> <br /> NO <br /> NO <br /> <br />,4' -1. 'i C,,T/t::. ~,~LNM=t'~'~ NO,, <br /> <br />PHONE: <br /> <br />TYPE: BUiLBZNG PERMIT OR APPLICATION NO: <br /> <br />I.,OlllkA(., fiji.,.,, ~,10,, <br />D f:) I'~ I,! ~]: I... 1.,, y ,~ ~:~ Y T I..i <br /> <br />PHONE :~ <br /> <br /> I T'EM <br /> <br />(~UII,,,DIIq(;; STA'¥E SU';tCHARIiE <br />ZON:[N(; SUR CHA F;;(;E <br /> <br /> P -~ V [ 0 LIS R !:_'g F: l P T ~ <br /> <br />FOLLOWING MUST BE COMPLETEB. IT IS TUE kESPO~S~BIL y , .... , , <br /> LL NECESSARY INFORMATION HAS BEEN PROVIBEB, I~ OF THE APPLICANT TO ASSURE THAT <br /> <br />FORM # MC 1~,1~6 REV. 4/90 OF FICE COPY <br /> <br /> <br />