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MARION COUNTY BUILDING INSPECTION <br />220 High Street NE <br /> Salem OR 97301 <br /> <br />800am-430pm Phone588-5147 <br />Code-A-Phone ~88-7904 <br /> FAX 588-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />F~on~ 7.- O / no~ ! D t <br />LeffSide ,~ I RightS[de S ~ <br /> <br /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br /> <br />RESIDENTIAL MfiRC:[AI, <br /> <br />] NewSI'D,a/garagc [ ] Acce~mr7 <br />Ne'.~ Si"D wio garage [ ] Relocate <br /> <br />° 9 199! <br /> <br />New [ ] S~gn <br />Addmon [ ] Demo <br />Alteration [ I Othc~ <br />Changc/Occupan~ <br /> <br /> MARION COUNTY <br /> I~llll rtlM~ INq:DEt~Tlnt,! <br /> <br />No Sc<>zit=~ , . Oros~ rloor Area:: m. Occupant ~ad <br /> <br />2. Location of Installation <br /> <br />Subdivl~mn ~t Block <br /> ......... <br /> A ~ ' ~ I~gl Private Well <br /> <br />3. Contractor Information <br />Property O~ncr Mailing Addm~ & Phone No <br /> <br /> Auth Agcm/l i!~ce Mailing ,Addrc~ & ])hone No <br /> <br /> Contractor Business Name & Number Mailing, Addmxs & Phone No <br /> <br />4. Septic Information (Check where applicable) <br /> Proposed No Redr(x>m~ '~ t'xi~ting No Bedrc'orn~::~ Nc'~ In~U~ahOn <br /> <br />Test llolcs Rcad~ [] Will Call When Test Ilole~ Read) ~ <br /> <br />5. Fee Schedules <br /> <br /> New ()~e-and.Two Family Dwcllin& Code 'v ahlatlon~ $.__ <br /> (includes El, Me,, PI) <br /> <br />(l)Sq Ft __x 28 = <br />(2) 5% State Surcharge (0fi ~t Al) = _ <br /> <br />(4) ?~ning Sari harge (If Applicable) = __ <br /> Subtotal:: $.___ <br /> <br />(1) Permit Fee <br />(2) 5% State Surcharge ( 05 x B I ) <br />(3) ?x,nin~, Sumha~ge ( 05 x BI) <br />(4) Plan~ Check (65 x BI) <br /> <br />Septic Fees (includes DEQ Surcharge) <br />(1) Site E,'~aluation <br />(2) New Septic J~lsmllatlon Permit <br />(3) AuthotJv. ation Notice <br />('I) L,xismlg System Report <br />(5) M'*jor Repair <br /> Minor Repai~ (milk ohly) <br /> <br />Mt~cellancou~ Fee~ '~/'}"- /~i~ ,,SD <br /> <br />(2) Driveway ~/o curb (~ $17 O0 <br />(3 SitePa~ {e~ c~ (cmnerca (mls)~$79~ <br />(4) ~we~tigatkm Fee <br />(~) Re~sp~tion }k'~e (~ $25 00 = _ .... <br />(6) O~er in~io~)~ not hsted abo~ e ..... x $40 = <br /> <br /> <br />