HomeMy WebLinkAboutSpecial Inspection Application 1984-9-5
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;Uepartment of Pub1ic W~
Bui1ding Safety Division
225 North 5th Street
Springfie1d. Oregon 97477
726-3753 (Bus.) 726-3?69 (Insp,.)
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TION
APPLICATION
DATE:
JOB ADDRESS: fie"7 Io-\~.."...... . A . s.r."", C..,.- S....,-nO" b" ,
OWNER:
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mlliERS ADDRESS:~/Y') r.th.rlp.M1/\ 1M ~ul::>, <:eR/NCFfeC-r.... /JU
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APPLICANT: '1<,'-,,"''''1> t=, ~"""".,," \), C,
APPLICANTS ADDRES S : .:;q S SO",." if"'-->- /=2",,:
FOR ACCESS TO PROPERTY--PLEASE INCLUDE TELEPHONE NUMBER: 4P,4--,.Q33.-.
7-1"7 - '274<" (.J;~" (IL,.",")
PROPOSED USE: \J ,,,,:: ';,."-,, - \('~ ('0;,<'-1"-'- S...'''c
A $30.00 INSPECTION FEE IS REQUIRED AT THE TIME
OF APPLICATION
THIS 4PPLICATION FORM MUST BE SIGNED BY THE 01mER OF THE PROPERTY TO
BE INSPECTED.
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SIGNATbr,f;
FOR OFFICE USE ONLY
DATE OF INSPECTION:
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RECEIPT NUMBER: lo34 ctx
DATEPAID:~~X'i\b.~ ~ ng4
DATE OF REPORT:
DATE OF CERTIFICATE OF COMPLIANCE:
COMMENTS: '\ '\ C......., \:l ~ i?\ W ~ '\
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