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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG NO 225 <br />220 HI~.,TREET NE <br /> SALEM FJ~EG~4N 97301 <br /> <br /> PHONE:: 588-5147 8::00 - 4:30 <br />24 HOUR CODE-A-PHONE; 588-7904 <br /> <br />The work will be porformod by a registered builder <br />Other. <br /> <br /> I have read and agree ~o the terms 8tsted on the reverse side of <br /> <br /> [,)A f E U?/(.]b/,~ ~ f ,~F4E: "/:34: 58 <br />OWNER I~ERN I , <br /> <br />SIGNATURE OF APPLICANT <br /> DATE <br /> <br /> TAX LOT <br /> <br />CATEGORY <br /> <br /> AU~SV;[t. Lb <br /> <br />MA~LING ADDRESS <br /> <br />SE <br /> <br />MARJT,,,1N COUNTY NO <br /> CAMELLIA H~tGH1b ~1 <br /> <br />SiTE NUMBER: <br /> VALUAFiON: <br /> <br />8994 <br /> <br />LOT <br /> <br />WIDTH <br /> <br />2S <br /> <br />BLOCK SSCTION TOWNSHIP RANGE : ZONE <br />DEPTH AREA UNITS IRSEG <br /> <br /> MAp <br /> <br />RA <br /> <br />TYPE: ELECtRiCAL PERNif OR APPLICAtiON NO: <br /> <br />I;{,)NfRACf©R, NO,, 63386 <br />LICgN3E NOt <br />,BI'<IbWQLD ELECIRIC <br />22866 JENNIE RD SE <br /> <br />PHON~: 859-22/4 <br /> <br />SUPERVLSiNG ELECTRiCIAN/NUmBER <br />~416~5 <br /> <br />gLbO]RICAL bT61E SURCHARGE <br /> <br />PAY~b,,: GRISWOLI3 EL&CTR[C <br /> <br />?OFAL A~SSED FEES <br />PREVIOUS RECeiPtS <br />THiS RECEiP'f <br /> <br />~ALANCE DUE <br /> <br />QUANT]TY <br /> 1 <br /> <br />AMOUNT <br /> SSS,co <br /> <br /> $3~."~ <br /> $OOO <br /> <br /> $OOO <br /> <br /> RECEiPt NO: 35288 <br /> ~.~V~B BY. UM2 TYPE: CX CHECK ~: 80? <br /> <br /> THIS IS A VALID P~IT * THIS PE~T ~PIRF,~ 180 ~YS F~ IT~ I~E DATE_ IF <br />~T~CTI~ C~ FOR A P~RiOD OF 180 ~YS, OR iF ~ST~CTi~ FAI~,~ lO M~EI ALL <br />~EQUIRE.~F:NTS OF STATE ~ ~D ~Ri~ ~NTY BUILDING ~D Z~ING ORDIN~C~, THIS PEril <br />~ALL BEdE NULL ~D ~ID. <br /> <br />REMARK'5: I~U AMP SERVIC~ NI;FFSB4 <br /> <br />13ON,LB E, NOOOLEY, MAM£ON COUNTY BUILDING OFFICIAL / BY <br /> <br />FORM ¢¢ MC 1 ~l ~ ~EV ~ OFFICE COPY <br /> <br /> <br />