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Appl. Revd; __ <br /> <br />By; :! ! ?;,,, ....... <br /> <br />Date~ <br /> <br /> 220 High St., N.E, 2nd Floor <br /> Salem, Oregon 97301 <br />FI.H. WlTHROW, BLDG. ADMINISTRATOR <br />588-5147 - 588-5148 <br />5;00 P.M.. ........... CODE-A-Phone 588-5373 ........... 8;00 A.M, <br /> <br />Type oj~'P~, ~ .... -- <br /> <br /> 10'ii~: .~ [ i4) " '" ' <br />Address; <br /> <br /> Tax Lot No; <br /> <br /> Sec. ~;? _Twnshp. , - ' Rge. <br /> <br />Address: ].0~,~} ........ <br /> .+ ) I). :. o !';~ <br /> <br />Bldr. & No.; Phone: Address: <br /> <br />Plans by: I~hone: Address: <br />Ma~l?a§e ] /~=~ Zone Chg. Pert.Cond. Use Variance I FireZone Occupancy Tyee of Const. <br />Use of Sldg.: , No Bdrms, Min R6~, Front Sides Rear <br /> <br />Lot No; BIk. No: <br /> <br />Water Supply: <br /> <br />Sewage ' ).'ifc <br />Disposal: <br /> <br />Area of Bldg: <br /> <br />Basement: <br /> <br />Heating <br />System; <br /> <br />Sub dy. Lot Size ] )0 ,;.; ?~rner? <br /> <br />Site <br />Evah <br />No. <br />Stories; <br /> <br />Roof <br />Type: <br /> <br />Valuation; <br /> <br />Permit Fee: <br /> <br />State Surcharge: <br /> <br />Plans Chk. Fee: <br /> <br />Septic Permit Fee: <br /> <br />Total Fees; <br /> <br />Rcpt. No: <br /> <br />PLANS <br /> <br />Date: <br /> <br />I agree to build according to the submitted plans and spec/f/cations, the lav~ of the State of Oregon and the Oridnance5ofMarion <br />County, Permit expirea if work not commenced within 120 day~. I furhter expressly warrant that I comply with lhe p~ovisions of ORS <br />701.005 to 701.125 because: <br /> <br />( ) lamaregisteredbuilderor( ) theauthorizedrepresentativeofaregisteredbuilder <br />( ) The work wi/Ibeperformedbyaregi~teredbugder <br />( ) I am perform/ng work on a property I own or occupy <br />{ )REMARKs:Otherfplea'e~pecifY] ..~L~_~_.~_ r .2,z, <br /> <br />SIGNATURE OF APPLICANT: ~~g~~ <br /> PLEASE NOTE'~walk inspectio~ar~ required by Public Works: 588-5036 <br /> v <br /> Other permits required by this dept: Plumbing [] Electrical [] <br /> <br />to the best of my know/edge. <br /> <br /> <br />