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Appl. Recd: <br />By: <br /> <br />Date~ <br /> <br /> MARION COUNTY <br />DEPT, OF BUILDING INSPECTION <br /> senatm Bui~ling <br /> p.20 High st,. N.E. 2nd'Floor <br /> ~lem, Oregon 97301 <br /> <br /> 58~614T b iM-~141 <br />5:00 P.M ....................... CODE-A~Phone ..................... .8:00 A.M. <br /> <br />Address: 1 ~ ~ ~ t?IAM A~[ ;~ ., ~r-'~- <br />~ldr. & NO.:: .,,~hone: <br /> <br />~63 8533 <br /> <br />Address: <br /> <br /> .Phon~ <br />Plans by: ......... <br /> <br /> I <br /> or ~ Ld,,: <br /> <br />Addres.~ -- <br /> <br />Lot No: ......... Blk, No_: ~ . Sub. dy.; <br />A~ of BI~O, 2ncl ~se- TOMI <br />Main Fir,; Fir.: _ ment: ........... Are~ <br /> <br />Roof Type: ........ Truss/~tlck- , ....... <br />Heating Wood Water <br />System ~tove~ . . Supply;, <br />Septic Tank New <br />Site EvaL: InstaL: <br />Exist. No, <br />System: .... Gale.: <br /> <br />VA~.iDATIONS: <br /> <br />Height;.,, <br /> <br />Valuation:., <br />~i~g, Permit <br />Fee: (+ 5%) ......... <br /> <br />C'~'~2*v , Elect. Fee; = <br /> <br />Mech, Fee: ~... <br /> <br />Plumb. Fee: . <br />6tate <br />Surcharge: (4%) <br /> <br />ZOning: ~ ~ /~ Mechanieal:: <br />Date: ..... fl l~. ~ -I I r~ete:,-~ ~ <br /> <br />I ag~ ;o build a;~tng to the su~i~ plans end e~ificatlOn~ the law; of the <br /> <br />NOT OOMMENCED WI THIN 180 DA YS_ I fu~her exp~e~ly waist that I comply with <br />fha pr~ie~ns of OHS 70t,~ to 701,125 ~auee: <br /> <br />I am l~erlorming work O~ a proper~y I owfl <br /> <br />I em a registered builder OR f ) the <br />authorized representative of a <br />reglt;tered bu#~er <br /> <br />( ) The work will be pedormed <br /> by a registered builder <br />( ) Other (please specify) <br /> <br />Plane Chk,, Fee: ..... <br />Septic Tank <br />Permtt Fee: ~O_ C~f) ...... <br /> <br />DEQ, Surcharge; <br /> <br />TOTAL FEr:: ~,~ ~ .~'~ <br />BLDG, <br />RECE(I~( NO.: ....... <br />Driveway <br />Permit Fee:, <br />Site Plan <br />Review ~. <br />Public Wor~s <br />Receipt NoJ <br /> <br />REMARKS:: <br /> <br />I have read this Application ltl its efltlrety arld certify that the stated information l; true and correct to the best Of my knowledge, <br /> <br />SIGNATURE OF APPLICAN - ,, <br /> fl <br /> PLEAS, E NOTBitDrlvewey and sldewa]k inspection are required by Publl~ Wor~$: 588~5036 <br /> <br /> Other permits required by this ~ept..' Plumbing n Ele~'Hcal ~ MeehantCal [] <br /> <br /> <br />