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MARION COUNTY PUBLIC WORKS 63,ctill 55 <br /> „,, BUILDING INSPECTION DIVISION �; l� L W E <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 a <br /> (503) 588-5147 Fax(503) 588-7948J ��3 ' <br /> http://www.co.marion.or.us/PW/Buildinglnspection MARION COUNTY <br /> BUILDING INSPECTION <br /> NOTICE AUTHORIZING REPRESENTATIVE <br /> Greg Brown have authorized <br /> (Property Owner/Print Name) <br /> Sam Mikolasy to act as my agent in performing the <br /> (Authorized Representative/Print Name) <br /> activities necessary to obtain site evaluations, permits, and other onsite wastewater treatment program <br /> services provided by the Department of Environmental Quality or County Agent on the property <br /> described below in accordance with OAR chapter 340, division 071. <br /> PROPERTY IDENTIFICATION: <br /> 5501 Lipscomb Street SE, Salem, OR 97317 <br /> Property Situs or Street Address <br /> Described in the records of MARION County as: <br /> Legal Description Tax Lot#(s) <br /> Subdivision, Lot and Block <br /> PROPERTY OWNER: <br /> Printed Name: Greg Brown <br /> Signature: Date: 11/28/23 <br /> Address: 5501 Lip omb Street SE Phone: 503-368-8441 <br /> City, State, Zip Salem, OR 97317 Fax: <br /> E-mail Address gbrown@II-fab.com <br /> AUTHORIZED REPRESENTATIVE: <br /> Printed Name: Sam Mikolasy <br /> Company Name: Skyline Builders LLC <br /> Signature: 12—:,"/ Date: 11/28/23 <br /> Address: 1280 Fir Street S Phone: 509-991-2573 <br /> City, State, Zip Salem, OR 97302 Fax: <br /> E-mail Address sam@skyline-co.com <br /> DEQ License# CCB # 234226 <br /> G:\FORMS\SEPTIC\S-07 AUTH TO APPLY.DOCX Rev 3/10,3/18 <br />