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,to Marion County D <br /> ECE [yEn <br /> �---li.�•• OREGON <br /> NOVawe 02 2020 <br /> PUBLIC WORKS MARION COUNTY <br /> BUILDING INSPECTION <br /> (503)588-5036 <br /> MARION COUNTY BUILDING INSPECTION <br /> BOARD OF DECLARATION OF PRIMARY HOME OWNERSHIP <br /> COMMISSIONERS <br /> Color Willis <br /> Sam Brentano The dwellin permit nd/o r septic permit being applied for at this address: <br /> Kevin Cameron 140 <br /> ,L \p CeiiX ( 5f C� isoradwng that is my <br /> w � 111���+ �} <br /> DIRECTOR primary residence for the majorityof each calendar ear. 7 ( <br /> Brian Nicholas,P.E. p y <br /> ADMINISTRATION <br /> Square footage of existing/previous dwelling: I/ 6a <br /> BUILDING <br /> INSPECTION #of existing Bedrooms:, #of existing Bathrooms: z.. <br /> EMERGENCY /� <br /> MANAGEMENT Square footage of existing/previous attached garage: ( � <br /> ENGINEERING I am providing as proof of primary residency a copy of one of the following <br /> documents: <br /> ENVIRONMENTAL ' <br /> SERVICES Driver's license <br /> ❑ Property tax record <br /> OPERATIONS o Utility bill <br /> PARKS o Bank or credit card statement <br /> o Pay stub <br /> PLANNING ❑ Voter registration card <br /> ❑ Other <br /> SURVEY <br /> I hereby declare that the above statements and evidence provided is true to the <br /> best of my knowledge and belief, and that I understand it is subject to penalty for <br /> perjury. <br /> Name: LC-0 rI (SO Y <br /> Signed: 0 ' <br /> Date: /0 r 30 7 0 7 7 <br /> Phone#: too – `7 � ^- O0 z3 <br /> 5155 Silverton Road NE•Salem,OR 97305-3802• www.co.marion.or.us/PW <br /> Printed on recycled paper• Reduce—Reuse—Recycle-Recover <br />