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SENATOR 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 OR ( ) the authorized representative SIGNATURE OF APPLICANT: <br /> of a registered builder. <br /> The work will be periormed by a registered builder, <br /> ) <br /> Other <br /> <br />TYPE: BUILDING <br /> <br />CONTRAC'F,gR~ <br />ADRZAN JEF'FERS <br />8795 JOEL CT SE <br />SALEM, 97~01 <br />PHONE: <br /> <br />PERMIT OR APPLICATION <br />24777 <br /> <br /> ]:TEN <br />f'4U t L:O'qq~ FEE <br />F'LAN REVIEW <br />BLI:,r, LDINE STATE SURCHARG~ <br />ZONING SURCHARGE <br /> <br /> ?B47444 <br /> <br />ARC, Ht TECT/ENLCt, NEER,~ NO,, <br /> <br />F'H 0 NE': <br /> <br />QUANT ]: TY <br /> <br /> AMOUN'f' <br /> $193,, 00 <br /> s125, 45 <br /> <br /> $9,6S <br /> ~TOTAL <br /> ~' REV I Ot,$~ RELEiPTS <br /> THIS, RECE]'F'T ¢3;¢7.75 <br /> BALANCE DUE <br /> P~YEE~I ADRIAN JEFF~:;.R,~ 49715 <br /> RECEIVED BY: PN '['YPE~ CK C',g~:CK ~: :1,6~3 <br /> <br />* THIS IS NOT A PERMIT., THIS APPLICATION MUST GO THROUGH A REVIEW PROCESS W~ERE THE <br />FOLLOWING MUST BE COMPLETED. IT IS THE ~ESPONSIBILITY OF THE APPLICANT TO ASSURE THAT <br /> LL NECESSARY INFORMATION HAS BEEN <br /> <br />SETBACKS: Fit- <br /> ,,,S ,' o <br /> <br /> PLAN,, ACTION: <br />CITY JURZ!~DZCTION: BY ........... DATE .................... ENERGY PATH: <br />R '-'MARKS. ' · "~ <br /> ADDN,, ~ BE,~ 8A <br /> , <br /> <br />FO~ # UC lSr~ R~V, ~0 OF FICE COPY <br /> <br /> <br />