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FOR OFFIC/~ USE/ONLY <br /> <br />MARION COUNTY ]BUILDING INSPECTION <br />220 High Street NE <br /> Salem, OR 97301 <br /> <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br />FOR 01?FICE USE ONLY <br />F(; to:t:i,TtS~RequireTeRne~: ~ <br />L,ft sid,: -5- / I me~, sid~:_5' < <br /> <br /> ONE & TWO FAMILY DWELLING PERMIT APPLICATION ,~ I~'~1 <br />COMPI,ETE ALL SECTIONS, 1THROUGI 1 4 ~]~[~ <br /> Job Description <br /> <br />I~llal'~ .......... <br /> <br />( ~5/ New Single Family Dwelling w/garag~ <br />( ) New Single Family Dwelling w/o gm'age <br /> <br />( ~Garage, attached <br />( ) Garage, delached <br /> <br />TRIss ( J~J or Rafter ( ) J No. Stories [Detached G~age l-Ieight: No. I~edrooms: ,~..~ <br /> <br />2. Loc-etlon of Installatlon <br /> <br /> ~ PrivataW*ll ( ) Spring ~ <br />La Widfl~ ~ ~ La De~h fl~C A~s I.eg. ~t ~) Comer ~O Commu~ty Well ( ) Ctiy <br /> <br />Contractor Information <br /> <br />Proper~yOwn~r ~d~-t'-/q''~ ~. /'~,~.C~$ J MailingAddrra~ ~7~jl,'/~ ~ ~-~b~.~ [PhoneNo. <br /> ( ) I own, reside in, or will reside in the completed strlzctllre, <br /> <br /> ( ) ! understand that I must register aa a co~x~traction contractor if the structure is sold or offered for salt before or upon completion, <br /> ( ) I will be my own General contractor, <br /> <br />If I hire subcontractors, [ will hire only subcontraCtors rcgict ered with the Construction Contra=fora Board. If I change my mind and do hire a general contractor <br />who is registerext wlth th¢ Construction Contractor's ltoard, [ will inmlediately notify Marion County of tho name of file cotltra¢or: <br /> <br />ConttactorBu$lnessnanle&#: /P )rk ta.c., S [Ma~llngAddr~ss: <br /> (t~l a,i, a registered builder OR. the amhorized representative of a registered builder, <br /> <br />Architect namer~,.~ ..~ t~f.~- S <br /> <br />4. Fee Schedule <br /> <br />A. N*w Ont,-and-Two Family Dwelling Cede <br /> (inleedes El) Me, PI) <br /> <br />(I) ¢'r~s~' -~ <br /> , .....,+ <br />(2) 5% State Surcha~e (.05 x Al) <br />(3) Plan Review <br />(~ppllcalale) <br /> <br />ga. 4sa gl/Z, 'O/e- <br /> <br /> B. Miscellaneous <br /> (1) Drlvew~y w/curb @. $7.50 = __ <br /> (2) Driveway w/o curb @ $17.00 -- __ <br /> (3) Additional Plan Reviews or Addendoms <br /> (4) Inve,qfigation Fee -- ___ <br /> ($) Rein;l~ction Fee @ $25.00 <br /> (6) Other Insl~e~)ons not listed abow <br /> <br />__.x $40 = __ <br /> <br />hereby certify fha.[thc above Jr~formation ia correct and thai have read and undera and t} e Inform on Nm e~ o l~tol~rty Owners al:mu Cons rue ion Responsibilities oa thc <br />~5-80 Rev, 17)2 <br /> <br /> <br />