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J.~ ~. ~i. "' ' '] '~ Salem, Or~gen 97801 j Left .~/*/~ I Right <br /> <br /> ~'~~/~ R [ '~ 'l ~nt I~kl"f'~/ Code-A-Phone 4~3e P M,,- 8::00 A.M <br /> <br /> PERMIT <br /> APPLICATION <br /> <br />Pro. er ty O~ner; / <br /> <br />-~ob Address <br /> <br />Mobile Home Perk <br /> <br />Phone:: M~iling ,~dd ress:: <br /> <br /> Site No <br /> <br /> PrOperty Tax Lot No <br /> <br />Sp # <br /> <br /> .___ <br />Cross S,treet <br />/ l <br />~ ~ Zone ' <br /> <br />Block <br /> <br />Total # Spaces:: <br /> <br />Lot Width Lot D~th Acres <br /> <br />~lZr rO~//./n e . Map <br /> Corn~ <br /> <br />Contractor Business Name and No <br />Architect/Engineer <br /> <br />Type of Permit J New ~' Addition:: [] Demo <br /> L <br />i~/~i~/./~ Alter [] Relocation ~J Ccc Chg:: <br /> <br />Height of Building No Stories Sq Ft Main Floor <br /> <br />Mobile Home Mobile Home <br />Width Length:: I '~J~_ <br /> <br />[] Tech <br /> <br /> Review <br /> <br /> Sq Ft 2nd Floor <br /> Occupancy <br /> <br />Address:: <br /> <br /> Use of Building "~,~'~- RES [; I <br /> <br /> 8q Ft ~t~ge ~Other <br /> Oco~m &cad { Wmer <br /> .... <br /> <br />Valuation:: <br /> <br />Proposed Septic Installation <br />Previous Site Evaluation <br /> <br />Type of_~ystem <br />Test Holes Ready <br /> <br />Will call when holes ready <br /> <br />Existing Septic System <br />Existing Tank Size <br /> <br />Existing Drainfield Length <br /> <br />Proposed Bedrooms <br /> <br />Existing Bedrooms <br /> <br />Bldg Fee <br /> <br />Mobile Home Fee <br />Fleet Surcharge <br />Zoning Surcharge <br />State Surcharge <br />Plane Check Fee <br />Site Evaluation Fee <br />Sepbo Permit Fee <br />DEC Surcharge <br />Technical Review Fee <br />Reinepecgon Fee <br />Investigation Fee <br />City lee <br /> <br />TOTAL FEE <br />RECEIPT NO <br /> <br /> <br />