HomeMy WebLinkAboutPermit Building 1975-7-23 (2)
LANE COUNTY SPECIAL PERlVtIT ABF.~"
NOTE: NO PERMIT. BE ISSUED UNTIL THIS APPLICAe HAS
APPLICATION FOR:
PERMIT 1F
BEEN APPROVED
~o" 3 ~;~
~,.AL, OWNE~' SJ1'1I'I-'A
~ Name
CONSTRUCTION P , MOBILE HOME C=:J PLAN REVIEW C=:J
cff II) ,B.llC cMlJ lJ ~AA..
Address city"
CHANGE OF OCCUPANCY c=J
,.,t/()/
Zip
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Phone ~
Name
.r'Am ~=
Address
City.
Zip
Phone
c====J CONTRACTOR
O.S. REG. n
Twp. ,17
Range
/) ~
Section
,;'~----Tax Lot
3~dO
Code 4t ~ t../
r
Property Acreage
Census Tract
Existing Structures on Property:
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ACCESS TO PROPERTY (Road Name;" /Je:/.l f)"yj!lAJ I'
I lit) We. e
Property Location - Address/Directions: ~ ~~~
Subdivision
Lot
Block
Width~Depth :J Yt>
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Below fo r Of f ice Use OnJxxxxxxxxxxxxxxyor,.,r,r,r,nr,r,rxxxxxxxxxxxxxxxxxxxxxxx,.",r",r.r,.,"{xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
./": /1 /) - r .... 'j' ~ Sq. F@/~. 10 flBedrooms Valuation
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L;NE (:O"J~!..f .3FE(:;lAL PERlifJ.lI A!llii~
SEWAGE DISPOSAL:
Site Inspection #
Existing Sewage Disposal System ~ or New System Required c====J
WATER SUPPLY:
Well Spring
Other
Public [=:::J
Community ~~
Name of Community or Public System (f(" ~ .~..;/.. )
Bldg.
Waste Disp.
Plumbing
Plan Review
Mobile Home
,3% Surcharge
J(I.() 0
PLUMBING':
Installed by Owner [=:::J
Other C=:J Name_
FEES:
PLUMBING FEES:
-
# of Fixtures
Sewage
Connection
Water
Connection
,;
PLANS FURNISHED
FACILITY PERMIT
,1"
~H
17' YES
C=:J NO
[=:::J YES ~ NO
TOTAL
M,:J{)
[=:::J CHECK
Signature of Applicant:
Fee Received By: C'} ~.A'.
17
. .-
Date:.~~=
, r
Dra1nfield Required - Lineal Feet . Maximum Depth
~~~,
..,..,.,11 ~:;.",)
.. -- .
~..eu.... ~
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.~
If)
Type of Construction
;{ AI Group
/
Fire Zone
Use Classification
Bldg SetbactsJ': from Center of Road Right of Way:
Front ~A SideInt.~ -"_:"..___:'-.r
,
Rear
~'
Zone...tt6r
OS.12
LANE COUNTY
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