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t O}~,ICE USE ONLY MARION COUNTY BUILDING INSPECTION <br /> 220 High Strut NE <br /> Salem, OR 97301 <br /> Validation: 8:00am.4:30pm Phone 588-5147 <br /> Cod~-A-~lone 558-790~ <br /> ~ FAX 58g-794g <br /> <br /> ONE & TWO FAMILY DWELLING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTiONS, 1 THROUGH 4 <br /> <br />1..lob Description <br /> <br />Tress ( kO <br />Square F~t: <br /> <br />( ) New Single Family Dwelling w/garage ( ) Garage, attacheat <br />(X') New Single Family Dwelling w/o garage ( ) Garage, detached <br /> <br />No, B~lroom.s: / <br /> <br />2. Locationoflnstallation ....... /~O ~- ~ <br /> <br />3, Contractor Information <br />~.~y ewer I Mailing Address , [ Phol~e No. <br /> <br />( JO I andcrstand that I must i~giste, r as a co~truction ¢ontraact ff ~e s~a~e is sold ~ ~d f~ afla ~ore or u~n ~l~6on. <br />~ I will ~ my own g~ne~ <br /> <br />Contractor Business nam~ & #: [ M-~ling Add~: [ Phone: <br /> ( ) ! am a registerad builder OR tho authorized representative of a regist~e~ed b~ild~. <br /> <br />4. Fee Schedule <br /> <br />A. Now One-and. Two Family Dwelling Code <br /> (jnleude~ El, Me, FI) <br /> <br />(g) 5% State Surcharge (.05 xA1) <br /> <br />(3) Plan Review <br /> <br />(4) ?x, rdng Suo:hoag~ ($15 if applicabl~) <br /> <br />V~luatiOm <br /> <br /> I hereby certify that the above information is correct and that I have tend and understand the hfforrnatioa Notice to Property Owners shoat Conswacfion Responsibilities on the <br /> reverse side of this fcxm. <br /> <br />MC l$-gO <br /> <br /> <br />