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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG. NO, 225 <br />220 HIGH STREET NE <br /> SALEM, OREGON 97301 <br /> <br /> PHONE: 588-5147 8:00 - 4::30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> <br />I am performing work on a property I own Or occupy. <br />I am a registered builder OR the authorized representative <br />of a registered builder. <br />The work will be performed by a registered builder, <br />Other_ <br /> <br /> ~HEPA~D. BOBBY <br />SITUS ADDRESS: <br /> <br /> 9161 SMi'f'tt RO SE <br />AUIV~SVI LLE OR 9?325 <br /> <br /> TAX LOT: <br /> <br /> CONSTRUCTION TYPE: <br /> <br /> CONTRACT CITY: <br /> <br />IvlAR ION COUNTY <br /> <br />5?858-008 <br /> <br /> UGB: <br /> <br />OCCUPANT LOAD: <br /> <br /> 5AM~ <br /> PHONE: ?49-240? <br />LOT: BLOCK: <br /> <br />: SECTION: I TOWNSHIP: <br />, 3. : AC <br /> <br />SITE NUMBER: 4904 <br />VALUA T I(;)N ¢ <br />SANGE: ZONE: <br /> <br /> 2W SA <br /> NO : NO <br /> <br />TYPE: ON-'S J: fie S~WAGE <br /> <br />PERMIT OR APPLiCAi,~ON NC): <br /> <br />C."f3N'f'RAC'T OR, NO. <br />~EPAR[.J, BO~BY <br />SA~E' <br /> <br />PHON b,: ';' 49-24 O 7 <br /> <br />NAI'ER ~PPLY; <br />'T'ES'f HOLES REAOY: <br />S11'E EVALUATION NUMBER: <br />EX~S'f~NG 'TANK <br />EXZS'f~NG ORAiN FIELD LINES: <br />SEP'T'~O 'IANK PUMPBD: <br />PREWIOUS NO, BEDROOMS; <br /> <br /> II'EM <br />ANNUAL E.VAL. - 'TEMP OR H~SHP ~ <br /> <br />TO'T'AL A~,~B~SSED FEES <br />PREVIOUS RECEZP'f'S <br />'l'Hi5 RECEIPT <br /> <br />QUANII1Y AIv1OUNf <br /> 1 <br /> <br />$60.00 <br />$60,00 <br /> $0.0o <br /> <br />BALANCE DUE $0_00 <br /> <br />PAYEE: RE,~iP <br />RECEIVED BY: c"i 'TYPE: CHECK <br /> <br /> SEE ATTACHED f,)OCUMENf FOR REQUIRP..JViEN'f'$ OF ON-SITE SEWAGE SYSTd% <br /> <br />* THi~ i~ A VALID PER,liT * THIS PERT*lIT EXPIREE~ 360 DAY~ FROt4 ITS I,%~UE OAl'~. IF <br />CONSTRUCTION FAILS TO ~EET ALL REQUIRET4ENT~ OF ~TATE LAN~ ANO r, tARiON COUNTY BUILDING AND <br />ZCNING ORDINANCES. THI~ PEF~IlT .E~rlALL ~ECOFtE NULL AND VOID. <br /> <br />RFZt4ARKS: HAROHSiP RENENAL R~3323 A~ <br />DONALD E_ WOODLEY, MARION COUNi'Y BUILDING OFFICIAL / BY ................................................................... ~ <br /> <br />FORM # MC 18-56 REV. 4¢~)~) OFFICE COPY <br /> <br /> <br />