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I am performing work on a property I own or occupy. <br />I am a registered builder OR the authorized representative <br />of a registered builder, <br />The work will be performed bY a regislered builder. <br />OTher <br />~ have read and agree to the terms stated on the reverse side of <br />this document, <br /> <br />MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 H,GH STREET NE ~ / L ~ <br />SALEM, OREGON 97501 .. <br /> <br /> PHONE: 588-5147 8:00 - 4:S0 <br /> 24 HOUR CODE-A-PHONE: $88-7904 ~k~~ .~' <br /> <br /> COF'F.~ GREGORY ! RESIDEHTIAL <br />SITUS ADDRESS: I CONSTRUCTION TYPE; , OCCUPANCY'. <br /> <br /> ~ .......................... ! O~UPRuT COAa: <br /> 11042 DAI_Y RI) NE ' CONTRACT CITY: UGB: <br /> AURORA OR ~Tee2 ~ARION COUNTY ',NO J <br /> <br /> 13442 CRA~ER LAKE CT .................................................... <br /> AURORA, OF, 97002 ~L, ..~/~ SITE HUHBER: ~4-039~8 <br /> PHONE: ~78-2~7~1 __~~ VALUATION: <br /> <br />WIDTH' ~DE~H' /AREA: UNITS' j iRREG. LOT: t CORNER; <br />........ ............. <br /> <br />TYPE: ON-SITE <br /> <br />PERN~T OR APPLJRATION <br /> <br />CONTRACTOR~ <br />GOFF. GREGORY <br />13442 CRATER LAKE CT <br />AURORA~ OR <br />PHONE: 678-2371 <br /> <br />9058786 <br /> <br />WATER SUPPLY: PW <br />TEST HOLES READY: <br />SITE EVALUATION NUMBER: <br />EXISTING TANK SIZE: <br />EXISTING DRAIN FIELD LINES: <br />SEPTIC TANK PUMPED: <br />PREVIOUS ilO. BEDROOMS: <br /> <br />TOTAL ASSESSED FEES $255.0~ <br /> <br /> PREVIOUS RECEIPTS <br /> TNIS RECEIPT <br /> <br /> BALANCE DUE <br /> <br />~AYEE: GOFF, GREGORY <br />RECEIVED BY: MB <br /> <br /> $0.00 <br /> $25%00 <br /> <br /> $0.00 <br /> <br /> RECEIF'T NO: 61276 <br />TYPE: CK CHECK 8~ 1472 <br /> <br /> SEE ATTACHF~) DOCUMENT FOR REQUIREMENTS OF ON-SITE SEWAGE SYSTEM. <br /> <br />:~ THIS IS NOT A PERNIT. THIS APPLICATION II'JUST GO THROUGH A REVIEW PROCESS MH~E THE <br />FOLL0~'iNG HIJST DE C0~PLETED. IT IS THE ~ESPONSIDILITY OF THE ~PPL[C~hlT TO ASSURE THaT <br />ALI,_ NECESSARY INFORMATION'HAS BEEN PROVIDED. ' ' <br /> <br />PLAN REVIEW: BY_ .~..__. DATE .L~_~L~-~..~L CITY JURISDICTION: BY DATE <br />KEMAI~I(o,, STD <br /> <br />b <br /> <br />OFFiC[~ COPY <br /> <br /> <br />