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MARION COUNTY IBUILIDING INSPECTION <br />SENATOR BLDG, NO, 225 <br />220 NIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-$147 8:00 - 4:30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br /> <br /> am performing work on a property I own or occupy. <br /> am a registered builder OR ( ) the authorized representative SIGNATUR~ OF APPLICANT: <br /> Of ~ registered b~ilder. <br /> The work will be performed by ~ registered ~uiider, <br /> Other <br /> I have read and agree to the terms Slated on the reverse side of OATE: <br /> this d~oument, <br /> DATE~ 06/24/94 T~ME: <br /> .. , ~ ~.., <br /> <br />~DRE~S: OCCUPANCY: <br /> ~ CONSTRUCTION TYPE: · <br /> <br /> 52~ SAN'~AN HWY N <br /> <br />ADbRES~i ................................................................................ <br /> SUBDIVISION: <br /> SHALL <br /> 88,4 I,]OI)t,tL. AN,~ DR <br /> ~ILVERTOI, I., OR 97~8~ S~TE NUHBER: ~4-~2498 <br /> ;:. Oh E ~ 873-'-424;~ VALUATZON: <br /> <br /> ~.~ ' 7,~ ~E R,:~ ' <br /> <br />TYPE: MECHANICAL <br /> <br />PERMIT OR APPLICATION <br /> <br /> ]: n c <br /> <br /> ITEM <br />F'OJ:~C A:[R F'URNACE UNDER 100000 BTU <br />DOMESTIC RANGE HOOD <br />DOMESTIC WOOI) STOVE <br />~OH EXMST FANS & DRYER VENT] <br />MECHANICAL BASE FEE <br />~L~CHANZCAL STATE SURCHARGE: <br /> <br /> _}RVILLE <br />F'AYEE~ ROTH,~ r" <br />Fd"_r CE ? VE D BY: <br /> <br /> $ THIS IS NOT A PERMIT. <br />FOLLOWING MUST BE <br /> Lt_ NECESSARY INFORMATION <br /> <br />TOTAl.. ASSESSED FEES <br />~REVIOUS RECEIPTS <br />THIS RECEIPT <br /> <br />BALANCE DUE <br /> <br /> QLtAN'f II'Y AhOUI,IT <br /> 1 $6 ,. ~8 <br /> I ~4.50 <br /> i $7,, 50 <br /> 2 $6.0~t <br /> $1~¢. 8~ <br /> $J... 7~ <br /> <br /> $S5,, 7~ <br /> <br /> INVOICE i',IO: saSaa <br /> TYPE: ;I;N CHECK ~ ~ <br /> <br /> A REViE~ PROCESS WHEE~ THE <br />THE APPLICANT TO ASSURE THAT <br /> <br /> OFFICE COPY <br />FORM # MC t 5,56 REV. 4/90 <br /> <br /> <br />