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MARION COUNTY BUILDING INSPECTION <br />SENATOR BLDG NO 225 <br />220 HIGH STREET NE <br /> SALEM OREGON 97301 <br /> <br />DA/E: 08111/9] ¥.f,M~; 16:08;45 <br /> <br /> KrOOSLEY, ALLEN & KAY <br /> <br /> 12235 WESI SFAYfON RD <br />AU~VILLE OR <br /> <br /> PHONE;; 588-5147 8::00 - 4'30 <br />24 HOUR CODE-A-PHONE: 588-7904 <br /> SIGNATURE OF ~PPLICANT~ ~~ <br /> OATE <br /> <br />CONS f HUC,~ ION TYPE <br />CONTRACT CITY UG8 j OCCUFANf LOAD <br /> <br />SUBDIVISION <br /> <br />9?325 <br /> <br />CATEGORY <br /> RbS [ 0~N l 1 AL <br />OCCUPANCY <br /> <br />NO OF BEb~OOMb <br /> <br />PHONE: 'NS 9-3,~4-L <br /> <br /> 18 <br /> <br /> 2.8 <br /> <br /> /'VALUAflON: <br /> ~ANGE ZONE <br /> 9~ / ~w ~P'u <br /> ?" IRRFG LOT CORNER <br />~ YES NO <br /> <br />MA P <br /> <br />fYPD: ON-.%'.iTE ~,EWAGF-, <br /> <br />PERIVi]'[ OR APPLiCA] ,[ON NO; <br /> <br />CON fRACfOR, NO. <br />W(X)SLbY, ALLEN & KAY <br /> <br />PHON F.,: 7r59-3~4L <br /> <br />9032884 <br /> <br />I NA~R 5UP,P. LY: PN <br /> FF. Sf HOLP~5 READY: <br /> <br /> I~FING F~K SIZE: <br />/bXISflNG DRAIN FIELD LINES: <br /> S6PriC f'~K ~MP~D$ <br /> PREVIOUS NO. BEDRO~: 2 <br /> <br /> i 1 EfVl QUAN '[ ,[ fY AMOUN <br /> AUfHORi,LAIiON NOIiC["; - FLD. ViSii¢~ 1 $105.00 <br /> / <br /> 701AL ~E~ED FEES $10b.00 <br /> ' PR~¥1OU~ R~CEI P rS $0 ,, 00 <br /> THiS RECEIP f $'10b.00 <br /> <br /> / ~x SALANCE mE , $0.00 <br /> PAYEE: ~..)r.~l..gy., ALLP-N & KAy ¥%~ RECE,IP!~ NO: <br /> <br /> A AON' DFoR R,mu R 'rs OF ON-SIrE ...................... <br />~ THIS .i.~ NOT A PEI~4,,I.T/' THI.~ APCLiCATION I~IIJST ~O TN~t.I~:~H A REV~E~ PROCESS I,,¢rlERE THE <br />FOLLO~NI~. I~iJ'~T BE COI~PI~ETED. IT IS THE R.E~PON,~IBI'LfTY OF THE APPLICANT TO .~,~..~------------~J~E THAT <br />ALL NLL"CE~AI;~F iNFOrmAtiON H.,t~ BI~I~N CROVIDED. <br /> / <br /> <br /> / <br /> PLAN N~:¥iEIN: BY ,,,,, DAi'r- Ci[Y JURI$DiCFION: 8Y DAIb <br /> ~,~bI'4ARKS: AUYH--¢~IE:L0 VIgil R~7720 <br /> / <br /> <br />FORM # MC 15-56 REv 4/~0 OF FICE COPY <br /> <br /> <br />