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Marion County 00-00 %4.z-----11° ( <br /> OREGON <br /> PUBLIC WORKS <br /> (503)588-5036 <br /> MARION COUNTY BUILDING INSPECTION <br /> BOARD OF DECLARATION OF PRIMARY HOME OWNERSHIP <br /> COMMISSIONERS <br /> _ . Colm Willis <br /> Sam Brentano , The dwelling permit and/or septic permit being applied for at this address: <br /> Kevin Cameron <br /> 3e0 F Ce47r9-1 6a13 Gkeis for a dwelling that is my <br /> DIRECTOR primary residence for the majority of each calendar year. <br /> Brian Nicholas, P.E. <br /> ADMINISTRATION <br /> Square footage of existing/previous•dwelling: /42o' <br /> BUILDING <br /> INSPECTION #of existing Bedrooms: 2 #of existing Bathrooms: <br /> EMERGENCY <br /> MANAGEMENT Square footage of existing/previous attached garage: 2 'U <br /> ENGINEERING I am providing as proof of primary residency a copy of one of the following <br /> documents: <br /> ENVIRONMENTAL <br /> SERVICES o Driver's license <br /> o Property tax record <br /> OPERATIONS o Utility bill <br /> PARKS o Bank or credit card statement <br /> o Pay stub <br /> PLANNING o Voter registration card <br /> o 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: R./ G c f/, fe, �►-ci <br /> Signed: <br /> Date: /1- -s / 4/- <br /> Phone#: 512.3 /O / `f// <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 />