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Receiwd By'?--~fDL~'/ : ;, ~,/~,I~IONa~OUNTY B~UILDING <br />City ~ / ~ Sen~r Bldg. No, 225 <br />Zoning V~ da~ ~ . 220 H gh ~tr~t NE <br />{ ~j ' L,~,k:? C X,Jh;TY Sa[em, Oregon9~01 <br />Date' yin' -- ~ Phone S38~147 <br /> <br /> BUILDING ~ MOBILE HOME ~ SEPTIC <br /> <br />INSPECTION <br /> <br />City Setback Requirements; _/_~ ,- <br />Front: 7_.01 Bear'. <br /> <br />Sde,. / Side: j <br /> <br />PERMIT APPLICATION <br /> <br /> Property Owner: <br /> <br />........ <br /> <br />Mailing Address: <br /> <br />Property Tax Lot <br /> <br />Cress Street: <br /> <br />Fleet S/C Zone: <br /> <br />Subdivision; ~ Block: <br />Mobile Home Park; Sp, ./l'; Total ~ Speces: <br /> <br />Section; <br /> <br />Lot Width: <br /> <br />Township: Range: <br /> <br />Lot Depth; Acres: <br /> ................... ,z :¥ <br /> <br />Irreg. LOt: <br /> <br />Map; <br /> <br />Contractor Business Name and No.: Phone; Address; <br />Architect/Engineer: Phone; Address; <br /> <br />Type of Permit; New: <br />"~t~ ~;;:' ~' ~, ~,- Alter; <br /> <br />Addition: [] Demo: E~ Tach, <br />Relocation: [] Ccc. Chg.: [] Review: [] <br /> <br />Use of Building; <br /> <br />RES ~J <br /> <br />COM ~ <br /> <br />Height of Building; No, Stories; Sq, Ft, Main Floor: Sq. Ft. 2nd Floor: Sq. Ft. Garage: Other; <br /> <br />Mobile Home Mobile Home ¢ Bedrooms; Occupancy; Occupant Load: Water Supply: <br />Width; Length: <br /> <br /> $_ <br /> <br />Proposed Septic Installation; <br />Previous Site Evaluation #: <br /> <br />Type of System'. <br /> <br />Test Holes Read[i._.~, ~ <br />Will call when holes ready; Proposed Bedrooms: <br />Existing Septic System: <br />Existing Tank Size; <br />Existing Drainfleld Length: <br /> <br />Type of System: <br /> <br /> Date Tank ?.u~m~e~di Existing Bedrooms; <br /> <br />,~ I have read this application in its entirety ~nd certify that the stated inforrn~tion t~ <br /> true and correct to the best of my knowledge, <br /> <br /> ) Oti~er <br /> <br />) I agree to build according to the submitted plans and specificatior~s, the laws <br /> <br /> Valuation: <br /> <br /> Bldg. Fee: <br /> <br /> Mobile Home Fee; <br /> Fleet Surcharge: <br /> Zoning Surcharge; <br /> State Sumharge: <br /> <br /> ~//~.oC~,. Plans Check Fee', <br /> I <br />4~ ¢';~O'OLO~'~'Site Evaluation Foe; <br /> Septic Permit Fee: <br /> <br /> ('~DEO Surcharge: <br /> Technical Review Fee', <br /> <br /> Reinspection Fee: <br /> Investigation Fee: <br /> City Fee; <br /> <br /> TOTAL FEE; <br /> RECEIPT NO,: <br /> <br />OTHER PERMITS REQUIRED BY THIS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />MC 15-6 <br />Rev, ~S/87 <br /> <br />~o ,_o, ,,0 <br /> <br /> <br />