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~' ~' I ~'¢ ~ TY-_BUILDING INSPECTION <br />City v y~ ~\ L~/Senator Bldg.. No.. 225 <br />Zoning Validation ~_.___ , ~ ~r ~ {~ 220 H gh Street NE <br /> <br /> Salem, Oregon 97301 <br /> <br />Date:; <br /> <br /> Prop~ Owne~ Phone:; <br /> JoD Address:; <br /> <br /> S~vision: Lot;: <br /> Mobile Home Perk:; <br /> <br />City_.S._etback Requirements <br />Front o,~ / Rear ~ / <br />Left ~'- ! Right <br />Side ~ <br /> Side;; / <br /> <br />PERMIT APPLICATION <br /> <br /> 'r M.~iling Address:; <br /> <br />8itc No:: Street <br /> <br />Property Tax ~o~t Nc:: <br /> <br />Fleet SIC ~ <br /> <br />q <br /> <br /> Block <br />Sp ~:: Total ¢/, Spaces:: <br /> <br />Lot De th <br /> <br />Map <br /> <br />c~-c~/)¢tor BuS'[Less Name and No <br /> <br />Architect/Eng,ineer <br /> <br />Phone;; <br /> <br />Type of Permit:: <br /> <br />Height of Building <br /> /,./, <br /> <br />Alter <br /> <br />Addition:; <br /> <br />Relocation <br /> <br />No Stories:: <br /> / <br /> <br />[] Demo [] Tach <br />~] Ccc Chg [] Review:: <br /> <br />Sq Ft Main Floor <br /> <br />Sq Ft 2nd Floor <br /> <br />Use of Building, RES <br /> COM <br /> <br />Sq Ft Garage:: <br /> <br />Mobile Home Mobile Home ¢ Bedrooms Occupancy Occupant Load r,Supply <br />Width :: Length ;: <br /> <br />Proposed Septic Installation:: <br /> Previous Site Evaluation ¢:: <br /> Type of System;; <br /> <br />Test Holes Read~:.. <br />Will cell when holes ready <br /> <br />Existing Septic System;: <br />.... ~xistlng Tank Size:: <br /> <br />Proposed Bedrooms: <br /> <br />Existing Dralnfield Length:; <br />Type of System:: <br />Date Tank Pumped Existing Bedrooms:: <br /> <br /> I have read this application in its entirety 8nd certify that the stated information is <br /> true and correct to the best of~e~lcmy owledge <br /> ~ am perferming work on a glop I own or occupy <br /> I am a registered builder OR (~fthe authorized representative of a registered <br /> builder <br /> The work will be performed by ~ regietered buitder <br /> Other <br /> <br />OTHER PERMITS REQUIRED BY THiS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />MC 15-6 <br />Rev 12/S7 <br /> <br />Valuation <br /> <br />Bldg Fee' <br /> <br />Mobile Home Fee <br />Fleet Surcharge:: <br />Zoning Surcharge <br />State Surcharge <br />Plans Check Fee <br />Site Evaluation Fee: <br />Septic Permit Fee <br />DEQ Surcharge:: <br />Technical Review Fee <br />Reinspeofion Fee <br />Investigation Fee <br />City Fee:: <br /> <br />TOTAL FEE <br />REOEIPT NO <br /> <br /> <br />