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City . ' ...... ~..,~,. <br />Zoning Validation: ..... <br /> <br />BUILDING [] <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> Senator Sldg, No, 225 <br /> 220 High Street NE <br /> Salem, Oregon 97301 <br /> <br /> Phone See-s147 <br /> Code-A-Phone a:3o RM, - 8;00 A,M, <br /> MOBILE HOME [~ SEPTIC [] <br /> <br />City Setback Requirem~ms: <br />Front; c7~,~ / Rear'. ~/ <br />Left ~,-.,~ / Right ~-/ <br />Side; ~ Sde: ~ <br /> <br /> PERMIT APPLICATION <br /> <br /> Phone'. Mailing Addres~ · ~/~-L.-4'~4.~/ <br />' ~-'. ~?n-~-~/ ~'(~, ~c~~~_,__~_~z:~ <br /> <br />Job Address: <br /> <br />· Site No.: <br /> <br /> Property, Tax Lot NO.: . <br /> <br />Subdivision; £~% , I _ / Lot: <br />'Mobile Home ' Sp, #; <br /> <br /> Range~ ?~_ Zone~.~ Map; <br />....Se~io. ', ~. Tow~,hip~; b~ ACreS:N~ ~frog' LO.: ~0¢-¢ <br />LOt Width; Lot Depth: ~-- Corner: <br /> <br />Fleet S/C Zone: <br /> <br />Block; <br /> <br />Total · Spaces: <br /> <br />Contractor Business Name and NO.: /~F' Phone;P,~0C~ ~'3~3~. O~L~ I Address; <br /> <br />Archltect/Englneer; ~ J Phone; ' ' Address: <br /> <br />Type of Permit: I New: ~ Addition; [] Demo: [] Tach. Usa of Building: RES <br /> <br /> I eOM <br />Vv~'~'~J~v'~'~ Alter; [] Relocation: [] Occ. Chg.: [] Review; [] YV'-~/~ <br />Height of Building; / I NO. Stories; 1 Sq. Ft. Main Floor; Sq. Ft. 2nd Floor: Sq. Ft. Garage: Other; <br /> <br />~ ~o~e' Mobile Home ; Occu : Load: :upply: <br />Width: I/4'..- Length,. ~_.¢ &, ~_. <br /> <br />Proposed Septic installation; <br />Previous Site Evaluation #: <br /> <br /> ..... '~ype of System: <br /> Test Holes Ready: <br /> Will call when hopes ready: Fy~poeed Bedrooms: <br /> Existing Septic System: <br /> Existin~ Tank Size; <br /> Existing Drainfield Length; <br /> _._Type of System; <br /> Oate Tank p~mped; Existing Bedrooms: <br /> <br />( ~')~11 have read thi~ applioatton In tLS entirety and car tify that the stated Informatlon is true and correct to the best of my knowledge. <br /> <br />( ) I am a registered builder OR ( ) the authorized representative of a registered <br /> <br />( ~Other <br /> <br />SIGNATURE OF APPLICANT,, ~_.... ;r'i~'~ J' <br />eTcHER PERMITS REQUIRED BY THIS DEPT.: PLUMBING, MECHANICAL, ELECTRICAL <br />Rev. <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 />Reinspection Fee: <br />Investigation Fee; <br />City Fee; <br /> <br />TOTAL FEE; <br />RECEIPT NO.: <br /> <br /> <br />