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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG. NO, 225 <br /> 220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE 588-5147 8 O0 - 4 30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am performing work on a property:l, own or occuC)y. <br />I am a registered builder OR the ~.uthorized represen ave 8 GNATURE OF APPL CANT <br />of a registered builder. ....... <br />Ot,erThew°rkwHIbePerf°r~edby~'~'giste~edbuilder'.. <br />I have read and agree to the terms stated on the reverse side of DATE'. ....... <br />this document. <br /> <br />SITUS ADDRESS; CONSTRUCTION TYPE; OCCUPANCY'. <br /> <br />SUBDIVISION[ <br /> <br />TYPE: BU~LB~NG PER~IT O~ APPLICATION NO: <br /> <br />;RU]:LI):U% F'E(:' <br />F'I.AN RE V Z I_:.W <br />BU:I:LD;~!4~ STATE SURI';HA~'J:: <br />ZOWZNI; SURCHAR[,E <br /> <br /> 7852S57 <br /> <br />A R C i..! :l: 'l" L'-': C T / E N £; ]: N E E R., N 0., <br /> <br />('~UANTIT¥ AHOUN'I' <br /> ~4 ,, ?3 <br /> <br />,[~ :1 .... ?i 9 <br /> <br /> 54810 <br /> 'f'YF'E: CK C, Fqi!;C,~' ~,: 2,53 i <br /> <br /> A REVIEW PROCESS WHERE THE <br />][RE APPLICANT TQ ASSURE ~HAT <br /> <br />FORM # M~ 15-~ REV. 4/90 OFFICE COPY <br /> <br /> <br />