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[~lJ L~ ~ PL~.I U uy~J~l[ ..... ~ ........ ~SenatorBuilding~2~S <br />~ Appl, Recd.:~ '~ ~J ~=~k],, : [ .; :il 7 220 High St., N.E~nd FIoor <br />U ~ ..... ~ '1' Salem, Orego~ 97301 <br /> ay:~I ~A~ R I 0 [~ COUNTY 588--5147 -- 588 5148 <br /> <br />Permit No.: <br /> <br />By;. <br /> <br /> Date; <br /> <br />Bldr. & No,: Phone:~ Address: <br /> <br />Plans by: Phone: ,,Address; <br /> Map Page Zone Zone Change Part. [ Cond. Use Vaaance/Adj. FT/¢O Occupancy <br /> <br /> -"'--' ~-OC c- ' <br />Lot NO.: ....... BIk. No,; Sub, dy.: .... '~- Lot Size:~'~O/'' I ~/~Corner?_ <br />Area of Bldg, 2nd Base- Total <br />Main Fir.: __.Fir.: ment: ...... Area: ValuatiOn: ...... <br /> <br />Type of Const, <br /> <br />Roof Type: , Truss/Stick:. J-ieight: <br />Heating Wood Water <br />System; Stove: Supply: ~l-'~ <br />Septic Tank New <br />Site Eval,: Instal.: <br />Exist. NO. <br />System: GaPs,: <br /> <br />VALIDATIONS: <br />Zoning: / ~ Mechanical: <br />Date: ti 1. Ill <br />Septic Tarbell/ // / C-.-~7Plans:Date:....... <br />Date: [,(...(j Y-'LO o/ ate: <br /> <br />I agree to build aCcOrding to the submitted plans and specifications, the laws of the <br />State of Oregon and the Ordinances of Marion County, PERMIT EXPIRES IF WORK <br />NOT COMMENCED WITHIN 180 DA YS. I further expressly warrant that I comply with <br />the provisions of ORS 701,005 to 701.125 because: <br /> <br />I am performing work on a property I own <br />o/' occupy <br />I am a registered bdilder OR ( ) the <br />authorized representative of a <br />registered builder <br /> <br />Bldg. Permit <br />Fee: (+ 5%) <br /> <br />Elect. Fee; <br /> <br />Surcharge~,,~ <br /> <br />Plans <br />Septic Tank <br />Permit Fee: <br /> <br />DEQ Surcharge: <br /> <br />TOTAL FEE: <br />BLDG. <br />RECEIPT NO.: <br />Driveway <br />Permit Fee: <br />Site Plan <br />Review Fee:_ <br />Public Works <br />Receipt No.: <br /> <br />( ) The work will be performed <br /> by a registered builder <br />( ) Other (please specify) <br /> <br />I have read this application in its entirety and~certlfy that thelstated information is true and correct to the best of my knowledge. <br />SIGNATURE OF APPUCANT: ~ ~ ~ ~'~g~~ )!/~b <br /> - PLEAS[ NOTE: Drivewa~'and sidewalk inspection are required by Public Works: 588-~036 <br /> Other permits required by this dept,: Plumbing ~ Electrical ~ Mechanical ~ <br /> <br /> <br />