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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG, NO, 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br />I am performing work on a property I own or occupy. <br />I am a registered builder OR ) the authorized representative <br />of a registered builder, <br />The work will be performed by a roglstered bullder, <br />Other <br /> <br />OWNER IitEN'rz,, KE:N <br /> <br /> SHAW HWY <br />~!,IMSVZLLE <br /> <br />USE OF BUILDING: <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br /> BATE: <br /> <br /> TAX LOT ( ~ATEGORY; <br /> ¥o'~sf~b6~16i4-f~ ..................... i~d~b~-~N~; .... <br /> <br /> O ~ CT C ~Y: UGB; I O°OUPANT LOAD. <br />OR 9732~; ~d,~,[~I,t LouN-f'Y qo <br /> <br />5828 SHAH H~Y o,-, <br /> <br />PHONE:',' <br /> ,.16,:. 6,.,,:3 <br /> <br />SITE NUHBER: <br />VALUATION: <br /> <br />'J. 8 FiR ].W <br /> AR5 ,1, 4.6, <br /> <br />TYPE= PLUHBtNG <br /> <br />PERHIT OR APPI-I£ATiOH NO: 9846~42 <br /> <br />AY,U:.,, KEI,II,IE'YH D. BEN-f'Z <br /> <br />TOTAL ASSESSE:I) i-EF_S <br />F'RIEV:~OUS RECEIPTS <br />fF ..... RECE:ZE'T <br /> <br />BALANCE DUE <br /> <br />,~ .I. 36 ...... <br /> <br />$ :1. 36,, 5E~ <br /> <br /> :':E :.-'." VF't) ~?Yll c:[ RE°El:PT NO: '~f-~"" <br /> ........................................................................ :.;;.;;:;:;:zzz::z=:z:z;=;zc:::=:;;;:;c= ....... · TM L. Clx CII!...E,~k ¢. J. 4,J7 <br /> $ THIS [S NOT a PErmIT. THiS ~PPLICATION HUST .................... <br />FOLLOWIN6 HUST BE COMPLETED. IT IS THE RESPONSiBILiTY: OF THE APPLICANT TO AS~URE'~ THAT <br />LL NECESSARY ZNFOR~ATION HAS BEEN PROVIDED. <br /> <br />F'i..AN REVZEI.¢; BY <br /> <br />REfffAIRI(S~ <',5Eala t::'T WL <br /> <br />DATE: <br /> <br />C,T. Ty JUR:t:SDiCT]:CtN; BY I)A'rE <br /> <br />.,1' <br /> <br />FORM # MC 15-~ REV. 4~0 OFF~CE COPY <br /> <br /> <br />