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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO. 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4:30 <br /> 24 HOUR CODE-A-PHONE: 588-7904 <br />~( )~. am gerformir~g work on a property I own or OCCUpy, T,~~ <br /> am a registered builder OR the 8uthorized representative SIGNATURE 0¢ AI~PLICAN <br /> of ~ registered builder, <br /> ) The work will be performed by a registered builder. <br /> Other .......... <br /> I have read and agree to the terms stated on the reverse side of DATE: <br /> this document, <br /> <br />'~RlU~d ^s ~'~S-'s: ................................................~'u~61Visidi4; 3 <br /> <br /> PO ]BOX 848 ..... f_ik-'~'H-- ................................. <br /> gANBY OR 97013 SITE NU~ER: 94-04112 <br /> F'NONE: 266-2792 I VALUATION: <br />ILOT: i BLOCK: SECTION; I TOWNSHIP; i RANGE: i ZONE: ; <br /> <br />TYPE: OH-~[TE SEI~IA~E <br />PERMIT OR APPLICATION <br />COHTRACTOR, HQ. ~;~4& <br /> <br /> WATER SUPPLY: PW <br /> TEST HOLES READY: <br /> SITE EYALUAI'~ON NUMBER: <br /> EXISTING TANK SIZE: <br /> EXISTING DRAIN FIELQ LINES: <br />I SEPtiC TANK PUMPED: <br /> PREVIOUS NO. BEDROOMS: <br /> <br /> ITEM QUANTITY AMOUNT <br /> REPAIR - MAJOR i $125,00 <br /> <br /> TOTAL ASSESSED FEES $125,00 <br /> PREVIOUS RECEIPTS $0.00 <br /> THIS RECEIPT $125,80 <br /> <br /> BALANCE DUE $8.88 <br /> PAYEE: BOB~S BACKHOE RECEIPT NO: <br /> RECE£VEQ BY: cl TYPE: CK 04ECK , 5325 <br /> SEE ATTACHED DOCUMENT FOR REQUIREMENTS OF ON-SITE SEWAGE SYSTEM. <br /> <br />~ THIS IS HOT A PERHIT. THIS APPLICATION HUST 60 THROUGH A REVIEW PROCESS I ~E THE <br />FOLLOWING MUST BE 60MPLETE~, IT IS THE RESPONSIBILITY OF THE APPLICANT TO ! ~E THAT <br />A . ~EC~SSARY INFORMATI1N ~AS BEEN PROVIDED. . , A <br /> <br />Pl.,AN M:.'~ IEW, <br />REMARKS: !SS: <br /> <br />]BY .... ~____ DATE'-_L~_'~-,,~t._"~L~__ 6ITY JORISDICTION: <br />M,JR,~REPAIR RENEWAL EROM CAHCELAT~ON <br /> <br />BY ri.'-'_' <br /> <br /> OFFICE COPY <br />FORM # MO 15-56 REV, 4,'90 <br /> <br /> <br />