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-ECEVED
<br /> • MARION COUNTY PUBLIC WORKS t
<br /> klif BUlIDING INSPECTION DIVISION MAR 2 2019
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<br /> 5155 Silverton Rd NE
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<br /> Salem OR 97305 MARION COUNTY
<br /> (503)588-5147 Fax(503)588-7948 BULDING INSPECTION
<br /> • http://wwvv.comarion.oraiS/PW/Bmidingloapection
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<br /> NOTICE AUTHORIZING REPRESENTATIVE
<br /> L. Skqeitck Le;rnci.etc___________________________________,have authorized
<br /> OperVO*01r/Pent 114
<br /> 1'4. •A Jig' i 0.1 I Ad . ar,'a' 1! /• ,e1 :to act as Toy agent imperformi g the
<br /> (Authorized Representative/ " ..!i Name)
<br /> activities necessary to Obtairvaiteevelnadonsi permits,rind other omit was obtain
<br /> program
<br /> nervieea provided by the DeparnnentnfEnvirOurn::entd Quality or County Agent=the-pro:Pe:1V ..
<br /> .desetibedbeiowinaneordaneelft'PARetaptar 340,div*n.on . ,
<br /> ,,,______________PROPERTY IDENTIFICATION-
<br /> .21G225 46a, .8tXt+eati IL a NE-
<br /> Property Situs or Street Address
<br /> And described in the records of MARION County as:
<br /> Legal Description Art,e,S. 14 4/1, Tax Lot#(s) 0' lelee./60
<br /> •PROPERTY OWNER:
<br /> Printed Name: \,(1/p_„ft, il\ek PUAYI..C3A, S,
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<br /> Signature: .. ,-;Th-. IA x_ Date: 5--f-a-7--ao N9
<br /> Address: Ap?(:).71 ti'Re. ,;--\--k-tAx.kk,L, ‘.12„...„‘A..k.._V\F_... Phone: :6-9A5-
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<br /> City, State,Zip k ji ,.c.c.,,---r-6..7 . -9 ... Cklillu*. ''aFax:
<br /> E-mail Address ' ,..e.v.\ta:,-.,_52:_ncicv (2_0_..6 to,--,:\_
<br /> AUTHORIZED'REPRESENTATIVE:,
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<br /> Printed Name: .Pit1404e- Adanic .kJ'. :t,tie.,,,--arm,* z e.,c_______
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<br /> Company Name:. gt:516--- 'ifereni, it:C:
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<br /> sigqatute: :, _,...., .,,,,..„: , ,,..F , Date; : -,_ ,?el,,I .-----7
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<br /> Address: - . ; -Zczygr...,..._ski2c): ,..Phone: 63..708.52t-'y
<br /> City,State,Zip Rfr-Werild/ 01 .q 12_6 i ` Fax
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<br /> E-mail Address rs cvliro1 a, iiIH:: :.. - m -.) ,.
<br /> DEQ License# .... CCB#
<br /> GAFORMS1SE2T/C13-07 Auth to Apply.doo
<br /> MCS-07 Rev 03/10
<br /> SEPTIC
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