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FOR OFFICE U~ ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br />~0 High Street NE <br /> Salem, OR 97301 <br /> <br />8:00 a.m,-4;30 p,m, Phone 588-5147 <br />Code-A-Phone 588-7904 <br /> FAX §88-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br />Left Side; .~ ! I Right Side: ,~ t <br /> <br /> DWELMNG/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job Description <br /> <br />RESIDENTIAl. COMAM 'ERCIAL <br />I.I New SFD w/garage [ ] Accessoq, [ ] New [ ] Sign <br />[ ] N~W SPD w/o garage [ ] Relocate [ ] Addition [ ] Demo <br />[ ] Addition [ ] De. mo [ ] Alteration [ I Otlter <br />[ ] Alteration [ ] Other [ ] Change/Occupancy <br /> <br /> Use of Building: <br /> No, Slorlas: I Basement: Y [ ] N [ ] [G~oss Floor Area, I I'Icight: { Occmpam Load: <br />2, Location of Installation <br /> <br /> .......... L, i ge ~-r',/.,, <br />Mobile ~[~ne Park Spa~ ~ <br /> <br />S~milon ] ~ Township ~ ~ Renge ) ~ 7~ne ~ - } Mep Water Supply: <br />~)/Width "~tD~ Aoms .... I~g. Lot ....... Comer Pr[vateWe~ [ ] Spring <br /> <br /> . ,, . ~ B ,,,~ ~ ..... Comm~ily Well [ ] City <br /> <br />3. Contractor Information <br /> <br />Property Owner <br /> <br />Auth, Agent/Imasco <br /> <br /> .~"~'Fee Schedules <br />Mail/rig Address & Pholl¢ No. A. New One-and-Two Family Dwelling Code <br /> (includes El, Me, Pi) <br /> <br />Mailin <br /> <br />,Contractor [3uslaess Name & Number Mailing <br /> <br /> Mailing Add.ss & Phone No. <br /> <br />4. Septic Information (Check where applicable) <br /> <br /> Pmpose. A No. BedrOoms: ~xis[ing No. I~cdroom$: N~w Installation [] <br /> Proposed Site Evaluat[or~ [~] <br /> <br />Te~t Holes Ready [] Will Call Whm Test Iloles Ready [] <br />Existing Site ~valuaIion [] Exis[ing Site Evaluat <br /> <br />Tank Size: <br /> <br />Existing Septic System <br /> <br />Existing Dra[nfield L~ngth: <br /> <br />Date T~nk Last lhlmped: <br /> <br /> ~pplicatjc~l in its entirety and certify that the:stated information <br />is tree and entree[ to the best of my knowledge. <br />I am performing work on a ptope~y I own or occupy. <br />i am a mg[stercA builder OR [ ] the authorized representative of a registered <br /> builder. <br />'the work will be performed by a registe~d huilden <br />Other <br /> <br /> I agree to b0ild according tn the submitted plan~ and epecificailon~, the laws of <br /> the stato of Ore onandtheol~llaance~ofMar~on nun <br /> <br />Signature of Al)pi/cant' <br />MC 15.73 Rev. 12-90 <br /> <br />YaluaUon: <br /> <br />(1) Sq, Ft. x .28 = <br />¢2) 5% State Surcharge (.0S x Al) -~ <br />¢3) Base Fee for Plan Review 185.00 <br />(4) Zoning Surcharge (If Applicable) <br /> Subtotal: $ ....... <br /> <br />(Permit fee detemaJ.ned by valuation. <br />· El, Mc, PI a~¢ separam permits.) <br /> <br />(I) Permlt Fee <br />(2) 5% State Surcharge (.05 x B1) <br />($) Zoning Surcharge (.05 x Bi) <br />(4) Plans Check (.65 x Bi) <br /> <br />Septic Fees (Includes DEQ Surcharge) <br />(1) Sire- Evaluation <br />(2) Ne-w Septic Installatioll Permit <br />O) Authodzatlon Notice <br />(4) Existing System Report <br />(5) Major Repair <br /> Minor Repair (lank only) <br /> <br />Valuation: <br /> <br />Subtotal: <br /> <br /> 15~.? <br /> <br />Miscellaneous Fees <br />(1) Driveway w/curb @ $7.50 <br />(2) Driveway w/o curb @ $1Z00 <br />(3) Site Plan Review (commercial only) @ $79.00 <br />(4) Investigation Fcc <br />(5) Rcir}sp~c0.m Fcc @ $25.00 <br />(6) Other inspertinm not lisb~J above <br /> <br />..... x $4(I = ,-- <br /> <br />Receipt: <br /> <br /> <br />