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Received <br /> <br />Zoning Validation: <br /> <br />Date; <br /> <br />Property Owns <br /> <br />BUILDING [] <br /> <br />MARION COUNTY BUILDING INSPECTION <br />Senator Bldg, No. 225 <br />220 High Street NE <br /> Salem, Oregon 97301 <br /> <br /> Phone 588-5147 <br /> Code-A-Phone 4:30 RM, - 8;1~1 A.M, <br /> <br /> MOBILE HOME [] SEPTIC [] <br /> Phone; Address; <br /> <br />City Setback Requirements: <br /> Front: Rear; <br /> <br /> Left Right <br /> Side: Side; <br /> <br />PERMIT APPLICATION <br /> <br />Job Address: <br /> <br />Site NO.: <br /> <br />Property Ta~o~,~ ~) <br /> <br />Cross Street; <br /> <br />Subdivision: Lot: Block; <br /> <br />Mobile Home Park: Bp, <br />Soctio~_,~ O~ Toweshlp; Zone: <br />Lot Width: Lot Depth; Acres; , Lot: <br /> <br />Total # Spaces: <br /> <br /> Contractor Business Name and No.: Phone; Address: <br /> <br />'~'~E~ Phone; Addreaa: <br /> <br /> Type of Permit: New: [] Addition; [] Oemo: [] Tach. Use of Building: RES Fq <br /> <br /> Alter: [] Relocation; [] Ccc. Chg.: [] Review: [] COM ~q <br /> <br /> Height of Building; No, Stories: Sq, Ft, 2nd Floor; Other: <br /> <br />Mobile Home <br />Width: <br /> <br /> Sq, Ft, Main Floor; <br /> <br />Mobile Home # Bedrooms: <br />Length: <br /> <br />Sq, Ft, Garage: <br /> <br />Valuation: <br /> <br />Proposed Septic Installation; <br />Previous Site Evaluation Cf: <br /> <br /> Type of System: <br /> <br />Will call when holes ready; Proposed Bedrooms'. ~" <br />Existing Septic System: <br />Exlstin9 Tank Size; <br />Existing Drainfield Length: <br /> <br /> Type of S~/$tem: <br />__Ba,.t_e Tank Pumped: <br /> <br />ExJstin¢~ Bedrooms: <br /> <br /> { have read this application in its entirety and certify that the stated information is <br /> true and correct to the best of my knowledge, <br /> I am performing work on a property I own or occupy. <br /> I am a registered builder OB ( ) the authorized representative of a registered <br /> <br /> Other <br /> <br />OTHER PERMITS REQUIRED BY THIS DEPT~: PLUMBING, MECHANICAL, ELECTRICAL <br /> <br />Water Supply; <br /> <br /> $. <br /> <br />Bldg. Fee: $ ..... <br />Mobile Home Fee; <br />Fleet Surcharge; <br />Zoning Surcharge; ....................... <br />State Surcharge: <br /> <br />Plans Check Fee: <br />Site Evaluation Fee; / ¢-]% o o <br />Septic Permit Fee: <br />DEQ Surcharge: <br />Technical Review Fee: <br />Reinspection Fee: <br />Investigation Fee; .............. <br /> <br />City Fee: <br />TOTAL FEE: /7_~' (:'cd) <br />RECEIPT NO,; <br /> <br /> <br />