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MARION COUNTY BUILDING INSPECTION <br /> 220 High Sl]-eet NE <br /> Salem, OR 97801 <br /> <br />8:00 a.m.-4:S0 p.m, Phone 588-5147 <br />Code-A-Phone 588.7904 <br /> FAX 588-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />Fr0.~ 2. O g ~'"' / O <br /> <br /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Job Description <br /> <br /> KES][DEN'I'IA[, COMMERCIAL <br /> [ ] NewSFDw/garage [ ] Accessory [ ] New [ ] Sign <br /> [ ] New SFD w/o garage { ] Relocate [ ] Addition [ ] Demo <br /> [ ~ Addition [ ] Demo [ ] Alteration [ } Other <br /> [ ] Alteration [ ] Other [ ] Change/OccupanCy <br /> <br /> Use of Building: ~ I~'~;, <br /> No, Storie~: I Basem~t: Y [ I N [ ] I Gross Floor Area: ]Height: [ Occupant Load: <br />2~ Location o{ Inotallation <br /> <br /> Site No. <br />~b~ l'i~e Park S~cc ~ <br />S~tlm j ~ Township ~ ~ Range j ~ 7me Map Wa[~ S~pply; <br /> Pfiva[eWe~ [ ] Sprir~g <br /> Width l~t Depth Acres ~ ~ [~g- L~ ~ Com~ ~O ~m~ity Wen [ ] City <br /> <br />3, Contractor Information <br />Property Owner Mailing Address & Phone No, <br /> ~/ d I./..4'.~2.,C2..ed' <br /> ail' ddre~ h <br /> <br /> Conrrac~or Business Name & Numar Mall~g <br /> <br />4. Septic Information (Check where applicable) <br /> <br /> P~os~ No. Be&~ms: Exist~g No, Bedims: New <br /> <br /> Existing Site Evaluadcaa Exist~g Site Evaluation No,; <br /> Proposed Installation Permit [] <br /> [[xisting Septic System [] <br /> Existing Dralnfield l~ngth: Tank Size: <br /> <br />[ ] Other <br /> <br />[ ,] i agree to bthld acoording to the submitted plans and specifications, the laws of <br /> the state of Oregon and the ordinances of Marion County, <br />$ignam~of Appliean,~ ~. ~ ... " <br /> <br />5. Fee Schedules <br /> <br />A, New One-and-Two Family Dwelling Code <br /> (includes El, Me, PI) <br /> <br />Vahtatiom $.__ <br /> <br />(1) Sq, Fi, , ..... x ,28 <br />(2) 5% State Surcharge (.05 x Al) <br />('3) tgase Fee for Plan Review 185.00 <br />(4) Zoning Sumharge 02{ Applinable) <br />Subtotal: $ <br /> <br />(Permit fee determined by valuation. <br />El, Me, PI are separate permks.) <br /> <br />(t) Permit Fee <br />(2) 5% State Sumharge $05 x B1) <br />O) Zoning Su~harge (,05 x BI) <br />(4) Plans Check (,65 x BI) <br /> <br />C, Septic Fees (Includes DEQ Surcharge) (I) Site Evaluation <br /> (2) New Septic Installation P~trait <br /> (3) Authofizalion Notice <br /> (4) Existing System Report <br /> ($) Major Repair <br /> Minor Repair (tank only) <br /> <br />Valuation: <br /> <br />Subtotal: $.__ <br /> <br />Subtotat: <br /> <br />D, Miscellaneous Fees (1) Driveway w/curb @ $7.50 <br /> (2) Driveway w/o curb @ $17,00 <br /> (3) Site Plan Review (oormmercial only) @ $79.00 <br /> (4) Investigation Fee <br /> (5) Reinapection Fee @ $25.00 <br /> (6) Other inspections ilot listed above <br /> <br /> x $40 <br />Total: <br /> <br />Receipt: ~3t~ ~, <br /> <br /> <br />