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Received By; ~ <br />zC~ir,g Validation; ~¢. <br /> <br />Date, <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> Senator Bldg. No. 225 <br /> 220 High Street NE <br /> Salem, Oregon 9730'1 <br /> <br /> Phone 588-5147 <br /> Code-A.Phone 4:30 P.M. - 8:00 A.M. <br /> E .OME [] SEPTIC [] <br /> <br /> City Setback Requirements: <br /> <br />PERMIT APPLICATION <br /> <br />.~/~r ty Ow~e. r: <br /> <br />Site No.: Cross Street; <br /> <br />Job Address: <br /> <br />Subdiceion: <br /> <br />Property Tax Lot No,: <br /> / <br /> <br />Lot; <br /> <br />Fleet S/C Zone: <br /> <br />Block: <br /> <br />Mobile Home Park; Sp. #: Total ¢ Spaces; <br />Sec~gi~ Towns~ Range: Map'. <br /> Acres: <br /> <br />Lot Width: <br /> <br />Lot Depth: <br /> <br />Irreg. Lot: <br /> <br />Contractor Business Name end NO.: <br /> <br />/Z.,//xlt eot / E ngina-er; . <br /> -- <br /> <br />Phone: <br /> <br />Phone; <br /> <br />Type of Permit: <br /> <br />Height of Building; <br /> <br />Mobile Home <br />Width: <br /> <br />New: <br /> <br />Alter: <br /> <br />Addition: [] Demo: [] Tach. Use of Building; RES <br />Relocation: [] Ccc. Chg.: [] Review: [] /~/~./' COM fi <br /> Sq, Ft, 2nd Floor; Sq~,~ge; Other; <br /> <br />NO, Stories; <br /> / <br /> <br />Mobile Home <br />Length; <br /> <br />Sq, Ft, Main Floor; <br /> <br />~'~ Bedrooms; <br /> <br />Occupancy; Occupant Load; <br /> <br />Proposed Septic Installation; <br /> Previous Site Evaluation #: <br /> Type of System: <br /> <br />Test Holes Ready: <br />Will call when holes ready: Proposed Bedrooms: <br />Existing Septic System; <br />Existing Tank Size: <br />Existing Oreinfield Length: <br /> <br />Type of System2 .... <br />Date Tank Pumped; <br /> <br />Existing Bedrooms: <br /> <br />I have read this application in its entirety and certify that the stated Informebon <br />true end correct to the best of my knowledge, <br /> <br />builder, <br />The work will be performed by a registered build,er/// <br />I agree to build a~cording to t he s~,cd~itted pl~/g ~l~e¢ifieatione, the I~w, of <br />the state of Oregon and the dtnances of ri n ounty. <br /> <br />OTHER PERMITS REQUIRED BY THIS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />MO 15.6 <br />Rev, 12/87 <br /> <br />Valuation; <br /> <br />Sldg, Fee; <br /> <br />Mobile Home Fee: <br /> <br />Fleet Surcharge: <br /> <br />Zoning Surcharge'. <br /> <br />State Surcharge: <br /> <br />Plans Check Fee: <br /> <br />Site Evaluation Fee; <br />Septic Permit Fee: <br />DEQ Surcharge: <br />TechnicS,Review Fee: <br />Reinspection <br />Investigation Fee: <br />City Fee; <br /> <br />TOTAL FEE: <br />RECEIPT NO.: <br /> <br /> <br />