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/ ~OR'OFFICE USE ONLYI <br />[ Zoning Validation; _ _ <br />[Date: <br /> <br /> ,~MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00am-4:30pm Phone 588-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br />ONE & TWO FAMILY DWELLING PERM1T APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job Description <br /> <br />baek Requi~emenB~: <br /> <br />FOR OFFICE USE ONLY <br /> <br />~).-New Single Family Dwelling w/garag~ <br />( ) New Single Family Dwelling w/o garage <br /> <br />( 39{ Garage, attached <br />( ) Garage. detached <br /> <br />No. Bedrooms: <br /> <br />Other: <br /> <br />2. L{mation of lnstallatlon 'x~6( R0 ~,~ = <br /> <br />Section ,/ ~ TownsMp ~ Range ~ <br />L~Wldth ~'Oefl7 L~De~ ~ ~'Acres ~ '" ~vateWell ~Spring ( ) <br /> ~ ~ Ieeg,~t Co~*r CommuMtyWeti( ) ,~ty ( ) <br /> <br />3. Contractor lnforlnation <br /> <br />Property Owner { Mailing Address ] Phone No. <br /> ~.J.o w n, r~ide in, cc will reside in the completed structure. <br /> <br /> ( ) I will be my owll general contractor. <br /> <br /> [ Ma~lJng Address: IPhone: <br /> ( ) Iarn a registered builder OR the authcciz~d representative of a registered builder. <br /> <br />.~a-chitect name: ]Mailing Address: I Phone: . I <br /> <br />4. Fee Schedule <br /> <br />A, New One-and-Two Family Dwelling Cad, <br /> (inlcude-s El, Me, PI) <br /> <br />(1) Gros~ Sq. Ft.. x $.28 <br />(2) 5% Stere Surcharge (.05 n Al) <br /> <br />(3) Plan Review <br /> <br />(4) 7aan~ng Surcharge ($15 if applicable) <br /> <br />Valuation: <br /> <br />B. Miseellanec,~s Fec.q <br /> <br /> (1) Driveway w/curb @ $7.50 <br /> <br /> (2) Driveway w/o curb {~ $17.00 <br /> <br /> (3) Additional Plan Reviews or Addendums <br /> (4) Investigation Fee <br /> <br /> (5) Reinspection Fe~ @ $25,00 <br /> <br /> (6) Other Inspections not listed above <br />RECEIPT: <br /> <br /> x SaO ~, ._ <br />TOTAL $ <br /> <br /> I hereby 9Crtlf~v ti,at the above mformauon is correct &nd that I have read and understand the Inf~tion Nadee o ~ny Owners ab~t Cons m~ on Re~ ns b e~ o fle <br /> <br /> Signature of Applicant~~ ' ' <br /> <br />MC 15-80 Rev, 1~2 ~.cxmn ~fore rebutting ~ s ~plJeation <br /> <br /> <br />