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MARION COUNTY BUILDING INSPECTION <br /> SENATOR BLDG. NO. 225 ~ ~ I <br /> ~ 920 HIGH STREET NE <br /> SALEM, OREGON 97301 j <br /> <br />PHONE: 588-5147 8:00 - 4:30 <br />24 HOUR CODE-A~PHONE: 588-7904 ~/~ /~ <br />, am performlr, g work on a property I own or occupy. ~/~_ //~.,~ <br />I am a registered builder OR ( ) the authorized representative SIGNATURE OF APPLIGANT; ....... ~ ............. <br />of a registered buiIder. <br />The work will be per;ormed by a registered builder, <br />Other. <br />I have read and agree to the terms stated on the reverse side of DATE; <br /> <br /> 87:~4 SHAW SQUARE R9 __ CONTRACT CITY'. ~ UGB, i OCCU,ANT LOAD'. <br /> AUHSVlL,LE OR 97~25 ~ARZON COUNTY~ NO <br />:U~ 0¢ BUILDING: <br /> <br /> ~ SITE HUMBER: 9~-~2771 <br /> F'NONE= 364-1655 ~ VALUATIOH: <br /> <br />TYPE: OH-SITE SEWAGE <br /> <br />PERMIT OR APPLICATION <br /> <br />CONTRACTOR, NO. 43:1.62 <br />Daniel Moreti: <br />5243 Scmnyview Rd NE <br /> <br />PHONE: <br /> <br />9849898 <br /> <br />WATER SUPPLY: PW <br />TEST MOLES READY: <br />SITE EVALUATION N[JMBER: <br />EXISTING 'fANE SIZE: 1000 <br />EXISTING DRAIN ~IELD LINES: <br />SEPTIC ~ANK PUMPED: W/BE <br />PREVIOUS NO. BEDROOMS: 3 <br /> <br /> ITEM QUAHI'ITY AMOUNT <br />AUTHORIZATION NOTICE - F'LD,, VISIT 1 $160.00 <br /> <br />PAYEE: MORRETT CONSTRUCTION <br /> <br />TOTAL ASSESSED FEES <br />PREVIOUS RECEIPTS <br />THIS RECEIPT <br /> <br />$160,00 <br /> $0~00 <br />$160.00 <br /> <br />BALANCE QIJE $0.00 <br /> <br />RECEIPT NO: 51~5 <br />TYPE: CK CNEgK ~: <br /> <br /> RECEIVED BY: PM .................................. <br /> <br /> $ THIS IS NOT A PERHIT.'THiS APPLICATION ~OST ~0 THROUGH A REVIEW PROCESS WHERE THE <br />FOLL. OWIN6 MUST BE COMPLETED. IT IS THE RESPONSIBILITY OF THE APPLICANT TO ASSURE THAT <br />ALL NECESSARY INFORMATION HAS BEEN <br /> <br />CITY JURISDICTION: BY ...................... DATE ............................ <br /> <br />~ORM # ~C 1~-~ R~. 4/~ OFFICE COPY <br /> <br /> <br />