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Marton CounLi)ty <br /> ID) E <br /> ,dl iWle i_ .. uOREGON NOV 2' 0 2o20 <br /> MART ON COUNTY <br /> ow. <br /> PUBLIC WORKS <br /> BUILDING 11SPEC`iON <br /> (503)588-5036 <br /> MARION COUNTY BUILDING INSPECTION <br /> BOARD OF DECLARATION OF PRIMARY HOME OWNERSHIP <br /> • COMMISSIONERS <br /> Colm_Willis <br /> Sam Brentano The dwelling permit and/or septic permit being applied for at this address: <br /> Kevin Cameron �,�y <br /> 25A-52— 4/ �l /M . t v �� /1Mr a dwelling that is my <br /> DIRECTOR primary residence for the majority of each calendar year. <br /> Brian Nicholas, P.E. <br /> ADMINISTRATION <br /> Square footage of existing/previous dwelling: 1-7, S-f• <br /> BUILDING # of existing Bedrooms: # of existing Bathrooms: <br /> INSPECTION <br /> EMERGENCY <br /> MANAGEMENT Square footage of existing/previous attached garage: L.) <br /> ENGINEERING I am providing as proof of primary residency a copy of one of the following <br /> documents: <br /> ENVIRONMENTAL <br /> SERVICES o Driver's license <br /> o Property tax record <br /> OPERATIONS o Utility bill <br /> PARKS o Bank or credit card statement <br /> o Pay stub • <br /> PLANNING o Voter registration card <br /> o Other <br /> SURVEY <br /> I hereby declare that the above statements and evidence provided is true to the <br /> best of my knowledge and belief, and that I understand it is subject to penalty for <br /> perjury. <br /> Name: /111011`-" 1-/i4epi ) .4 <br /> Signed://00,._ <br /> Date: f ll " 7—V <br /> Phone#: 5D3 er(— D l <br /> 5155 Silverton Road NE•Salem,OR 97305-3802• www.co.marion.or.us/PW <br /> Printed on recycled paper• Reduce—Reuse—Recycle-Recover <br />