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<br />i SitLl~ ADDRESS:
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<br /> 5858 SHAkr !"iWY
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<br />Other .....
<br />J have read and agree to the terms stated on the reverse side of
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<br /> MARION COUNTY BUILDING INSPECTION
<br /> SENATOR BLDG. NO. 225
<br /> 220 HIGH STREET NE
<br /> SALEM, OREGON 97301
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<br /> PHONE: 588-5147 8:00- 4:30
<br /> 24 HOUR CODE-A-PHONE: 588-7904
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<br /> ampe orrf ngworkonapope y DY.
<br />Iof a regis, tared builder,am a registered builder OR ( ) the authorized represer~tatlve SIGNATURE
<br />The work will be performed by a registored builder.
<br />
<br /> DATE:
<br />
<br /> SE
<br />97525
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<br /> TAX LOT ....
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<br /> DONSTRUCTION TYPE O~OO~A~:
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<br />'~-"~ T'C'T~ .......... UGE' ..... I08'CU~A~ ~OAD' '
<br /> ~A~.(~?N COUNTY NO ,
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<br />,.~8,..8 SFIAkl HWY SE
<br />F',,£ ~,r..;,, ;62.-4;53
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<br />SITE NUi'IBER:
<br />VA L UA T Z[ Otq:
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<br />PERMIT OR APPLICATION NO: 984~40
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<br />EONTRAC'f'OR,~ NO.. 58258
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<br />11;~73 HJ.].I Creek Rd
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<br />PHONE:: 769-7744
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<br />WATER SL;l:'i~ ..~/// /
<br />'r~:sm 140LE,~I~:/~ ~,'-//'~/~'~
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<br />~EF'TZC T~NK F'UHF'ED~
<br />F'REVZOUS NO,,
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<br /> !TEH
<br />S~ A!,;DARD 0 N,,-S '.FTE.
<br />S', TE EVAL. Lh-%T]i[!N, FIRST LOT
<br />
<br />) A ,J.,, Kii!;NNETH
<br />RECE ]:VE'O B'¢':
<br />
<br />TOTAL ASSLo,:)ED FEES
<br />PREV];OUS RECE'~ZPTS
<br />TI"i.[,,~ RLF;I:,I~ f
<br />
<br />BAL ANSE DUE
<br />
<br /> BENI'Z ' IRECEIPT NO,'. 48559
<br /> "?YF'E: CK Ct,,~[:Z;;iK 4(::I 1457
<br />SEE ATTACHED I)OCUMENT FOR REQUIF('EMENT,C,~ OF ON'"',,$1TE SEWAGE
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<br /> · ' 'e .,HFLY PF'RMISS],'ON TO BtJ];LI) ON ]'I-1ZS F'ARCEL. PI...AN!,!]]N¢ AND
<br /> NOTE: fHL(,,~ ~)OES NOT [;R~NT OR ~ .... . .......
<br />[;NSTRUCTI[]N ;:q~[~:~lT~~ ~../.~'US~.OBTA;[N~'~ BEFORE I~[J:[LD]J,IG OR SEFIT);C TNSTALLA'TJ[ON f-)EGTNfL,
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<br />FOR~ # MC ~-,~ ¢t~V, 4/W OFFICE COPY
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