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j~~ MARION COUNTY <br />-' DEPT. 'OF BUILDING INSPECTION <br /> <br /> ppL Reo~ ~ __ ~0 High St., N_E. ~nd Floor Permit <br /> Salem, Oregon 97301 <br /> ~ C~ <br /> ~-' --86 5.00 P M ....................... CODE-A Phone ................. 8;00 A.M- Dat~ <br /> <br /> Owner. US FOIST ~ mddress'~~ <br /> JIM ~' Ph°~e'~54--3360 <br /> Bldr & NO. Phone'~ Addres9:~ H~ ~ ~X <br /> Plans by, -- Phone.~ Address: <br /> <br /> ~ Of ~ldg ........ I NO Bdr~s. '" Min Req Front <br /> <br /> Lot No.- ..~lk. No ..... Sub. dy ' ~ot Size'~~orner? <br /> Area of Bldg. 2nd ~ase- Total <br /> Main Fir; Fir.. ~ent Area: Valuation ..... <br /> BJdg Permit <br /> Root Type_ Tru~/Sti¢k H~ight' Fee: (* 5%) <br /> He,tin9 Wood Water <br /> Syetem ~tove . . Supply: Elect. Fee <br /> Septm Tank New <br /> Site Eval Instal Mech. Fee:~.~ <br /> Exist. Nd. <br /> System: .~. Gals.- Plumb Fee <br /> State <br /> VALIDATIONS Surcharge;.~4% <br /> Zoning: Mechanical- <br /> Dam ~,¢ .Bateh Plans Ch~. Fee <br /> <br /> ,agree to bu,ld ,,cording tO the ,ubmitted plans andspecificatio,,, the laws Cf the <br /> <br /> ( ) I am performing wor~ on a prope[ty / own ( ) The work wdl be perforCE Dnvewa~ <br /> or occupy by a reglsrere¢ builder ~e~ee <br /> ( ) I am .... a registered builder OR ( ) the ( ) Other ...../Dlea~e specify) ~ <br /> autnor~ze~ repre~e~tahve o¢ a <br /> registered buil¢er Review Fe~:,, <br /> Public Wor~s <br /> Receipt No <br /> <br /> REMARKS <br /> <br />I i~aw read thia aPi~lioetten tn Its entirety and certify that the stated fnformetion is true and correct to the Peat Of my knowledge. <br />SIGNATUREOFAPPLICANT~ ~~ ...... <br /> <br /> <br />