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~'h 6~ihcw us~. ONLYI MAroON cour~rv ~vmm~o ~se~cx~o~
<br />~ --~- Xf~-; ~.. ~ 220 High S~t ~
<br />I Re~'v~ Y: ~~]_~ S~, OR 97301
<br />I Zoffing V~li~ ~~ '- 1 ' 8:~,~.4:~ ~c 588.5147
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<br />[,, ~ ' i t I g~ 588-7948
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<br />~E ONLY
<br />I City S~baek Reatuirement~:
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<br />1. Job Description
<br />( ~New Single Family Dwelling w/garag~ ('t.~arage, arrayed
<br />( ) New Single Family Dwelling w/o garage ( ) Garage, detached
<br /> BL~ILDtNG t~S?ECl~OIq
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<br />Other:
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<br />2. Location of Installation
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<br />F~0,,,.,Ow.er L),,r,-¢~ .... [~,~"~gadd,.,~a.g.,* ,,L~S ,;a~/,-,~7 ,,, ¢~* gx~Y .......
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<br />...... ~;a,ll,. &. q~ s~,~o. . ........
<br />I MoNle Ilomc Pi~k S~ce ~
<br />,~=,o~si~;"'~o.=~o ~s ,a.,~ ~ W ......... zo~ ~S. ~;0 .... w~=~;; .......
<br />L~Width ~' L~De~h /0~,03 Acres hIeg.~t ~ Cota~t ~0 CommunltyWell()) City
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<br />3. Contractor Information
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<br />I ~li.g Addres~a~m~ ~ ~' ~ ,bo ~.~ff.~ ] Phone No.
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<br />( ) I own, re.side in, m will reside in the completed structure.
<br />( ) I understand that I must register as a ¢onstrueQon contractor if the 5tincture i~ sold or offered for sale before or upon completion.
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<br />( ) , wl]] be my own general contractor, 7~,~,~-C--
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<br />wi o is registered wi~h fle ConsLruc~ion Contractor s Board, I will immediately notify Marion County of the name of th~ ¢ontracor:
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<br /> (',~ i am a, r~istc,~d builder OP~ the anthorizcd mp~csentatiw of a registe~d b~ildet
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<br />Archltectname: ~.~O,~,~q~. ,,OX
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<br />IMailing Address: [ Phone:
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<br />4. Fee Schedule ................................
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<br />A, New One-and-Two Family Dwelling Cod~
<br /> (inlcud~ El, Mc~, PI)
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<br />(t) Oro~s Sq, m. _ld~l.., x $.28
<br />(2) 5% State Surcharge (.05 x Al)
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<br />(3) Plan Review
<br />(4)~' ? s ~ ...... ~ ~
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<br />Valuation: '$_-//~uo{5'~
<br /> =
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<br /> =
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<br />Miscellaneous Fees
<br />(1) Driveway w/curb @ $7.50
<br />(2) Driveway w/o curb @ $17,00
<br />(3) Additional Plan P~vi~ws or Addeedums -
<br />(4) InveslJgafion Fee -~ ......
<br />(5) Reinspecfon Fee @ $25.00 = --
<br />(6) Other Inspections not listed above = __
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<br />reverse side of this form, /
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