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FOR OFFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br />8:00 e,m,-4:30 p.m. Phone 588-5147 <br />Code-A-Phone §g8-7904 <br /> FAX 588-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br /> DWELLiNG/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Job Description <br /> <br />RESIDENTIAL COMMERCIAL <br /> sPD w/gar,ge <br />N~w SPD w/o garagc [ ] Relocat~ [ ] Addition [ ] Demo <br />[ ] Addition [ ] D~mo [ ] Altcratio*~ [ ] O~cr <br />I I Alleralinn [ I O~er [ I ~ange/Occllpancy <br /> <br />No, Stories: <br /> / I I , :~ ' [height: /~/ I OccupantI~ad: <br /> <br />2. Location of Installation <br /> <br /> 'Fax ct. No C $~e ~ .~ <br /> <br />Se~doa ~ Townshi~ ~'ng~ ~n, ~: Map Water Supply; <br /> ..... Comm~ityWell [ ] City <br /> <br />3. Contractor Information <br /> <br /> ~-a: z~ acs <br /> <br />5. Fee Schedules <br /> <br /> Mailing Address & Phone No. <br /> <br />4. $~Dtie Information (Cheek where applicable) <br /> <br />Test lloles Reedy [] Will Call Whim Test Holes Ready [] <br />l[xisl~lg Site Evaluatic~l [] Existing Site Evaluation No,: <br /> <br />I!xi~ting Scplic System [] <br />](Msting Drainfield Length: Tank Size: <br /> <br />1) e la~k ~ts Pumped: <br />Pull.e3 Poi2ii Attached [] <br />i~F I have reed this application in its entirety and cCrlify that the staled information <br /> <br /> (~-m I performing work on a propmty 1 own or occupy. <br />[] '['I am a rcgi~mr~d builder OR [ llheauthorizcdrcl>rcsentativeofarcgi~temd <br /> builder. <br /> 'me wm,k will be perfomled by a registered builder. <br /> (~:her <br /> me state of Oregon annette >rdinan~e~ of'M~{~on Cq~ult~ ._~_ <br /> <br />A. New One-and. Two Family Dwelling Code Valuation: $ z~%~'4~-J~' ~- <br /> (includes El, Me, PI) <br /> <br /> (2) 5% Slate Surcharge (.05 x Al) <br /> (3) Base Fee for Plan Review <br /> <br />g. Stmc*uml Pe~it <br />(Penni{ fee detemfined by valuation. <br />El, Me. PI am scparale peruke.) Valuation: $... <br /> <br /> (1) Pe~it Fee <br /> (2) 5% State Surcha~e (.05 x B 1) <br /> (3) ~ning Snvchargc (.05 x BI) <br /> O) Plans Check (,65 x <br /> <br />C, Septic Pee~ (l,lcludes DEQ Sufcbarge) (1) Site Evaluation <br /> (2) New Seplic [nstatlatlon Pemfit <br /> (3) Aulhod~ation Notice <br /> (4) Existing Syslem Report <br /> (S) Major Repair <br /> Minor Repair (lank only) <br /> <br />Subtotal: <br /> <br />Misccllancons Fees <br />(1) Driveway w/curb @ $7.50 <br />(2) Driveway w/o~curb @ $17.00 <br />(3) Site Plan Review (cc~nmerclal only) @ $79.(X) <br />(4) I.vesligalion Eec <br />(5) Reinsp~ction Fee @ $25,00 <br />(6) Other thspeclinn~ not lislcd above <br /> <br />..... x$40v Total: <br /> <br /> <br />