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MARION COUNTY <br /> .__ .~ ~ ~ ;~ ~IIE~T~F B~]LDING <br /> INSPECTION <br />Appl, Race.: ; W ~( ~ (~Jgh St., N.E, 2nd Floor Permit NO,: <br /> ¢ ~ I~ , ~ "" Salem Oregon 97301 <br /> " ~ ~ 588~5147-- 588-5148 By;, <br /> <br />Bldr. & No,; Phone; Address: <br /> <br />Plans by: __Phone: Address; <br /> <br /> .... Min Req, Front Sides Rear <br /> <br />Let No.:_ .:. .Sub, dy.;., Lot Size: ,, Corder?, <br />Area of Bldg. 2nd Base- Total ~ ' <br />Main Fir,: __Fir,: merit;. Area: Valuation: <br /> Bldg, Permit <br />Roof Type~ Truss/Stick; Height; Fee; (-- 5%) <br />Heating Wood / Water <br />S~stem: .Stove: __/~ ~Supply: <br />Septic Tank ~' New <br />Site Eval.; .Instal,; <br />Exist. No. <br />System: .Gals.: <br /> <br />VALIDATIONS: <br />Zoning: Mechanical: <br />Date; I ~ .... Date; <br />Septic Tank: ~,~r''"'~ ~ ",, X} ~/~Plan~: <br />Date: <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, P£RMIT EXPIR£S IF WORK <br />NO T COMMENCED WITHIN 180 DA YS. I further expressly warrant tt~at 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 /> or occupy <br />( ) I am a registered builder OR ( ) the <br /> authorized representative of a <br /> registered builder <br /> <br />( ) The work will be performed <br /> by a registered builder <br />( ) Other (please specify) <br /> <br />Elect. Fee: <br /> <br />Mech. Fee:_ <br /> <br />Plumb. Fee: ...... <br />State <br />Surcharge:_!4%) <br /> <br />Plans Chk, Fee: <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 />4 3.1%' <br /> <br />Oot. LJ_ '7 <br />have read 's application in its entirety and certify that bl~ted inf, ormation is true and correct to the ~est of my <br />SIGNATURE OF APPLICANT: ///~¢~ V% ~ <br /> PLEASE NOTE: Driveway and sidewalk inspection are required by Public Work~: 588-5036 <br />MC <br />REV 7- SS Other permi~ required by this dept,: Plumbing B Electrical ~ Mechanical B <br /> <br />knowledge, <br /> <br /> <br />