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��: , I'i-efabricate. �tructures Inspection 1�� !� ��
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<br /> i'�.`..�"_ Dcpartment ol'Cousumer.� Qusiness Ser�'ices J Urc��rnt
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<br /> ` '�`> t>.�� Ruildiu�Codes Dicision • 1?3�Gd!!c�catcr A\1'. Salcm. ��l:
<br /> � 'rey� \laitiug address: P.O. Bu� I-�-17U, Salcm. OR 97309-0404 [] Idtthb
<br /> �;03�� 378-3080.1�❑s: (,0:3)373-U�_'8.'I"fl': (;n3� 373-13;i+ ] Otlier: —
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<br /> TYPE OF INSP'ECTION J" �""
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<br /> C� Visual 0 In-plant � In-suuc J tipcci�il ❑ On sue ❑ Out of statc
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<br /> � �*+�YF�' ' i� INSPECTION INFORMATION ,. ';:,.�_
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<br /> � � /�>.._ �Date rcyu�st�d:� ,? ,
<br /> V�r.namc�' / ,� .-� �.�:� _���----' �l:itc a( ins �ccuon < -
<br /> / ,','./�n , /— I Insudlation location_. :
<br /> Inspccuonlocatinn: /p' �: , �
<br /> ! , y . ^ � Cantactperson:�o; / ' %- '�'
<br /> Party w bc billed: G'!�_� .-, '�`- �
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<br /> , � ` ` Time out�i Insi�m i��sued: ❑l�es ❑\u
<br /> . i�.- Time m:/� �-- _
<br /> Inspectornmu � r�,��. . � ,; , . � . „ 1---- �
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<br /> �I�inal ❑Re•inspection
<br /> ❑ 5 -70711 1190 �P- 7UGll 1191 ❑ S -?0-11 If'�0 � I'-?UG111191 ❑5 -707ll 1190 ❑P-70611 I191
<br /> � \(-70;1111)(� ❑ *L-%(itllll'�I �, � VI -�O"II1190 :� ' :-�O1111191 ❑\1 i0711�1190 O '1' 70ll111J1
<br /> ' INSPECTION REPOFiT _ - '
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<br /> � Iuspectiou timc:_ � - Toltil how'ti
<br /> Invoicc ln iblln�c. Includc p:n'mcut for all ins �eclious — ._ -
<br /> pert'm•mcd dui in}ciilet�d�r iuoull�. P:q'ment due 30 Cousulla�iun: ` �
<br /> da�s 1'rum biihny,clatc ' j� . � ":J 1-huur
<br /> ; 1�� -; .' 8�� surch;ugc(�inici.mccl�): (70 i ll. I_911
<br /> Receivetl b�:-+ . Dn[c: ' - miuimum
<br /> � � � b'-�surchmec (Plumbin�_l: (706111^_)I1
<br /> R'��surcl�:ugc l�lect�icah : (70ll 1�1291)
<br /> �� DPI"\RT��41:NT Of
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<br /> le� USINESS `�
<br /> �SLI���ICES jccond cu i� 1 ilc l�hird cu i��-�f�muLiciurer �C1�P --_ Q� �_
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