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MARION COUNTY BUILDING INSPECTION IFOR OFFICE USE'ONLY <br /> 220 High Street NE [ City Sethack Req~tlmmenta: <br /> Salel~a~OR97301 IF t '" ~,~t¢ R~ar t' <br /> <br /> F~ 588-794g ~ ~ <br /> BUmD~G PERM~ APPLICAT~ 0 Y 199~ <br /> <br />COMPLETE ALL SECTIONS, ] TIIROUOH 4 <br />i. Job Description MARION COUNTY <br /> <br />2, Location of Installation <br /> <br />SuMMsion i ~ Bl~k <br />Mo~e Home Pa~ S~ce ~ <br /> <br />~Wid~ ~ O t L~De~ ~g ~ Acres I~g.~t Comer ~mu~tyW~ ( ) City ( ) <br /> <br />3. Contr actor Information <br /> <br /> ( ) I and:nmnd ~at ~ must ~st~r as a ~ ~ ~ s~gum ~ ao~ or ~e~ for sa~ <br /> <br />Conuaetor Bus~gss n~e & ~:. .~ ~~~' M~g Addmss: ::' ' [ Phone: <br />4, Fee Schedule <br /> <br /> I (1) Driveway w/cuxb@ $7.50 <br />Valuatlon: $.,,-~'~, ~O (2) Driveway w/o cu~ ~ $17,~ <br /> / ~* ~ O) $i~ Hah ~ew (~memial mly) ~ $79.~ <br /> (4) A~fli~nal Plan R~ews or <br /> <br /> Z77 <br /> <br />TOTAL <br /> <br />I hereby certify that the above in/ormatlon is correct and that I have mad and understand the Infofmatlou Notice Io PrOperty Owners about Cotlstmcl/on ResponsibilidSs on the <br /> <br />NameofApplicant(PleasePr~m): ~"~ l Cq,c ccoo-: Phone: <br /> <br /> ~ ' .- ; ff ff ¢~ Date: <br /> <br /> ~hc cvaload~s, septic, ~le~cal, plumb~g ~d mechaniCal woA mqulm se~mtc pc~Rs, Che~ wi~ Mafi~ County B~ld~g Insp¢~oa ~fom <br /> <br />MC 1~-73 Rev. 11/91 <br /> <br /> <br />