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Fgli OFFICE USE ONLYi <br /> Received By: -- <br />] Zoning Validat{on: <br /> Date: <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00mn-4:30pn Phone 588-5147 <br /> Cod~-A-Phor~ 5g8-7904 <br /> FAX 588-794g <br /> <br />ONE & TWO FAMILY DWELLING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 TItROUGH 4 <br /> <br />1. Job Description <br /> <br />ONLY <br /> <br />( ) New Single Family Dwelling w/garage ( ) Garage, attached <br />~)New Single Family Dwelling w/o garage ( ) Garage, detached <br /> <br />3. Contractor Information <br />Pro~y Owner IM~ling ~drms IP~n* No- <br />~I own, r~ide in, ~ will t~id~ in ~e eompletad s~. <br /> <br />If I hire su~on~or~. I will ~ only gu~on~t~ reglst~M wi~ <br /> <br />who is regist~M wi~ ~e Cous~ion Con,actor's B~, I will im~a~ly n~fy M~on County of~e name ~* con~r: <br /> <br />Contractor Business name & Il: [ Maihng Addr~s; ] Phone: <br />( ) I am a reglsmred builder OR th~ authorized representative of a registered builder. <br /> <br />4. Fee Schednle <br /> <br />A. New On,-and-Two Family Dwelling Code <br /> (inleude~ El, Me, PI) <br /> <br /> (1) Gro~s Sq. Fi. '~7.--"x $.28 <br /> (2) 5% State Surcharge (.0S x A1 ) <br /> <br /> (3) Plan Review <br /> <br /> (4) Zoning Surchavg¢ ($15 if ~pplicablo) <br /> <br /> I hereby 9ettify ~at the above information is correct and that I have read and und~ratand the In/orrmtion Notice to Property Owners abo~t Construction Responsibilities on the <br /> reverse ~de of tlus form. <br /> <br /> , Phone: ' <br /> <br /> Signature of Al)plleanC Date: <br /> Site evaluations and ~eptic work require seperate permit~. Check with Marion County Building Inspection b~fore submitting this application, <br />MC 15-80 <br /> <br /> <br />