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FOR OFFICE USE ONLYI <br />'Rec~i,~ed By: __ _ ] <br />Zoning Validation: _ ] <br />Date: [ ] <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00am4:30pm Phone 585-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br />ONE & TWO FAMILY DWELLING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job Description <br /> <br /> FOR OFFICE USE ONLY <br /> City Setback P.~qtdremem: <br /> <br />I Front: Rt~t: <br />Lett Side: Right Side: <br /> <br />New Single Family Dwelling w/garage ( ) Garage, attached <br />New Single Family Dwelling w/o garage ( ) Garage, detached <br /> <br />Tras~ (?'9 or Rafter k~, } No. Stories ~ ]DetachedOarage Hclghi: No. Bedrooms: ~ <br /> ..... Sec. ond Hoer' Other: <br />gq. F t: IMai" ° :Z?do'J .......... '/67 e: ge-s' <br /> <br />2. Locatinn of Installation ~R-~-i; 6t~C~.~q ~O/g~ <br /> <br /> o,oe/J:,_ J ,,6/4,f! ~et JMailing^ddr~s <br />$u~Jvision ~ ~l~k <br />Mobile Hom~ P~k S~ce ~ <br /> ..... ~ivamW~ll ~ S~ng ( ) <br /> Aer~ <br /> ~eg. ~t <br /> Cm~ <br /> ~ffO Com~,,-l~yW~ll( ) City ( ) <br /> <br />3. Contractor Ilfformation <br />Propeny Owner J Mailing Ad&e~$ J Phono No. <br /> <br />~ 1 own, reside in, or w reside in the completed stmetam. <br /> <br />If I hire subcontractors, I will hire only subcontractors registered with the Construction Contra~thrR Board. ff I change my mind and do hire a general contractca- <br />who is registered with the Constmetlon Contractor's Board, I will immediately notify Mmlon County of ~he name of the eontracor: <br /> <br />J Mailing Address: [ Pho0e: <br /> <br /> ( ) I am a registered builder OR the allthorized relxesenhative of a registered builder. <br />~a'¢hJteet name: l? ~". /~/~ L4 g'L.~' <br /> <br />,,~. Fee $chedu,!~ <br />A.,~New One-and. Two Family Dwelling Code <br /> 0nleude,~ El, Me, PI) <br /> <br />(1) Gross Sq, Ft~_~x $.28 <br />(2) $% State Smcharge (.05 xAI) <br /> <br />(3) Plan Review <br /> <br />(4) Zoning Surcharge ($15 if applieaEle) <br /> <br />%luatiom $__ <br /> <br /> 00 <br /> <br />B, Miscellaaeetis F~s <br /> <br /> (1) Driveway w/cxmb @ $7.50 <br /> <br /> (2) Driveway w/o curb @ $17.00 <br /> <br /> (3) Addltiona/Flat~ Reviews or Addendums <br /> (4) Investigation Fee <br /> <br /> (5) Reillspecfion Fcc @ $25.00 <br /> <br /> (6) Other Inepeetion~ not listed ahoy* <br />RECEIPT: <br /> <br /> reverseI herebYsideeertifo[fl~isfl~atfoem.thc above ilfforinafion is correct and that I have read and understand the Information Notice to Pro~rly Owners about Construction Responsibilities on the <br /> <br /> S',~ evaluations and ~epOc wo,~re secretary.. Chec,~ M~ounty B~ldthg Im.~ion ~fore sub~thng ~s ~plicetion. <br />MC is-so <br /> <br /> <br />