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~EI~IOF B~J. ILDI~IG INSPECTION Senator Building <br /> <br /> Salem, O~gon 97301 <br /> aY: <br /> <br /> Tax Lot NOJ <br /> <br />.. A,d,esa: <br /> <br />tldr, & No.:_ <br /> <br />...... Phone: <br /> <br />Address; <br /> <br />Plans by: ..... <br /> <br />PhOne; .~ Address: <br /> <br />Area of Bldg, 2nd Ba~- Total <br />Main Fir.; ~lr.: ment; Ama;, <br /> <br />Root Type: .... Truss/Stick: Height: <br />Heating WOod Water <br />System: Stove: ,~upply: <br />Septic Tank New <br />Site Eval.: InstaL: <br />Exist- No. <br />System: Gala,: <br /> <br />VALIDATIONS: <br />Zoning; Mechanical; <br />Date: ,, Date: <br />Septic Tank: Plans: <br />Date: r)ate: <br /> <br />Lot Size: <br /> <br /> Valuation: <br /> I~ldg. Permit <br /> Fee: (+ 5%) <br /> <br /> Elect. Faa; <br /> <br />.. Mech, Fee; <br /> <br />Plum, b, Fee: <br />State <br />Suroharge: (4%) <br /> <br />Plans Chk. Fee: <br />Septic Tank <br />Permit F~e.e: ......... <br /> <br />I agree to ~uild according to the submitted plans and specifications, the laws el the <br />Stale of Oregon and Ilia Ordinances of Marion County. PERMIT EXPIRES IF WORK <br />NOT COMMENCED WITHIN 180 DA YS, I further expressly warrant that I comt~ly with <br />tl~e provisions of ORS XO 1.005 to 701.125 because: <br /> <br />I am performing work on a property I own <br />or Occupy <br />I am a/egisterecl builder OR ( ) the <br />authorized repre,~entatlve of a <br />registered builder <br /> <br />( ) The work will be performed <br /> by a registered builder <br />( ) Other (please speolfy) <br /> <br />DEQ Surcharge: <br /> <br />TOTAL FEE: <br />BLDG. <br />RECEIPT NO,; ...... <br />Driveway <br />Permit lee; <br />Site Plan <br />Review Fee: <br />Publlo Works <br />Receipt No,: <br /> <br />REMARKS: .- <br /> <br />have reed this application in its entirety and certify that the stated information is true and correct to the best of my knowledge, <br /> <br />SIGNATURE OF APPLICANT: ............. <br /> PLEASE NOTE: Driveway and sidewalk tnsPeotion are required by Public Works: 5~8-5036 <br /> <br /> <br />