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FOR CITY VALIDATION Received By: [Zoning Validation: IDate: /-?,2 -e~, I MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St. NE - Room 132 Salem, Oregon 97301 8:00am-4:30pm Phone 588-5147 24 hr. Inspection Line 588-7904 FAX 588-7948 FOR CITY USE ONLY City Setback Requirements: Front: ~ Rear: 5 ! Side: I htSide: ' ONE & TWO FAMILY DWELLING PERMIT APPL~~ ~ ~ ~/75-~ ~"~ COMPLETE ALL SECTIONS, 1 THROUGH 4 *Includes electrical, mechanical, plumbingfees]~~.~l~~j~j ~ JAN 1 6 ~3~ 1. JOB DESCm~ION ({ ¢- 14 [ 0 ' 2 ?~ ( ~ew Single F~ly Dwelling Wi~ Attach~ G~age MARION COUNTY ( ) New Single F~ly Dwelling With Detach~ n~age BUILDING INSPECTION ( ) New Duplex Energy Path: ~ No. Stories / I ~e~ched ~arage.eight: No. Bedrooms:3 Square Feet: Basement:: [ Main Floor: /3/3 Second Floor: Garage: ~/~"O Other: 2. LOCATION OF INSTALLATION Cross Street Sn ivision IMailing Address Section o~' Township ~5~-~ Lot Width ~7 6' '~ Lot Depth ~ 7.50 IRange o~ ~ Acms ~. ~ ~/ 7.~o~ J PhoneNo. 3~t~- b 7/(t:, Comer ~fO ( ) Spring Community Well ( ) City Ta~cct. NO.Lot o~~qLoo / O~ -- ~7" F ~ Zone ~ ~ Map Water Supply: Private Well Irreg. Lot 3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that I must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will Mre only subcontractors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the Construction Contractom Board, I will immediately notify Marion County of the name of the contractor. I am a CONTRACTOR registered with the State of Oregon. Business Name ~ . Registration No. MailingAffdress~/t0 ~ ~ ~. ~ Phone I am an AUTItORIZED REPRESENTATIVE of thc property owner or contractor. Name (pleas~ print) Mailing Address Phone 4. FEE SCHEDULE VALUATION: Gross Sq Ft / 7~ x 64.66 1. PERMIT FEE: GrossSqFt II'Tb~ x $.315/sqft * Building @ .1700 per sq ft Electrical @ .0600 per sq ft Mechanical @ .0200 per sq ft Plumbing @ .0650 per sq ft TOTAL $.315 PER SQ FT 2. PLAN REVIEW FEE: GrossSqFt../7b$ x $.0950/sqft $ /~, 7.4? B. PERMIT FEES I. Permit Fee (A-l) 2. State Surcharge (5% of A-l) Plan Review Fee (A-2) 3. 4. ~ Z ...... ,, S ...... ~ t,. .... vv-~-'Jl'e) 5. Investigation Fee ($.41 per sq ft) 6. Reinspection Fee $25.00 7. Other inspection $40.00/per hr (1 hr min.) 8. Overtime inspections $40.00/per hr (2 hr min.) 9. Footing/Foundation Only $25.00 - County Use Only TOTAL Dwelling labels must be obtained at Marion County Building Inspection and must be placed at the jobsite prior to inspection for plumbing, electrical and mechanical work. Contact Marion County for instructions. I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. Name of Applicant (Please Print): / Phone: Signature of Applicant: ~ ~ ,~Ji~- Date: /~ '~ -- ~* MC 15-80 Rev 1/95