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k <br /> <br />FOR OFFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 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 588-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br />F~t: Rear: <br />Lef~ Side: Right <br /> <br /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job Description <br /> <br />~ I I Site No. <br />SubdiviSion .... Lot ~,~ Block <br />Mobile Hc~c Park_._.,, Space # <br />Section [~ Township(~ Range ~/ Zone F, CU Map L(3 Water supply: <br />Lot Width Lot Depth Acres Irreg. Lot ' C~mer Private Well 0,~pring [ ] <br /> CommunisyWell [ ] City [ ] <br /> <br />3. Contractor Information ~J 5. Fee SChedules <br /> <br />Architect <br /> <br />No. <br /> <br />4. Septic Information (Check where applicable) <br /> <br /> Proposed No. Bedrooms: Existing No. Bedrooms: New Installation [] <br /> Proposed Site Evaluation [] <br /> <br /> Test Holes Ready [] Will Call Whea Test Holes Ready [] <br /> Existing Site Evaluation [] Existing Site Evaluation No.: <br /> Proposed Installation P~rmit [] <br /> Existing Sel~ic System [] <br /> Existing Dralnfield Length: Tank Size: <br /> Date Tank Last Pumped: <br /> Pumper Form Al~ached [] <br /> <br />I have read this applicatinn in its entirety and certify that the stated information <br /> is u'ue and conect to the b~st of m <br />I am performing work C~ a property <br />I am a registered builder OR [ ] <br /> buildex. <br />~'ne work will be pedormed by a re <br />Other <br /> to the submitted the laws of <br /> the state o <br /> <br />A. New One-and-Two Family Dwelling Code Valuation: $.__ <br /> (*include s El, Me, P1) <br /> <br />(1) Sq, Ft. x .28 = <br />(2) 5% State Surcharge (.05 x Al) =__ <br />O) Base Fee Inr Plan Review = 185.00 <br />(4) Zoning Surcharge (if Applicable) = -- <br /> Subtotal: $ <br /> <br />B. Structural Permit <br /> (Permit fee determined by valuation. <br /> El, Me, P1 are separate permits,) <br /> <br /> (1) Permit Fee <br /> (2) 5% State Surcharge (.05 x B1) <br /> (3) Zoning Sun:barge (.05 x B1) <br /> (4) Plans Check (.65 x B1) <br /> <br />C. Septic Fees (includes DEQ Surcharge) (1) Site Evaluation <br /> (2) New Sulxic InstalLation Pennis <br /> (3) Authorizati~m Notice <br /> (4) Existing System Report <br /> (5) Major Repair <br /> Minor Repair (tank only) <br /> <br />Valuation: <br /> <br />Subtotal: $.__ <br /> <br />Subtotal: $ <br /> <br />Miscellaneous Fees <br />(1) Ddveway w/curb @ $7.50 <br />(2) Driveway w/o cuth @ $17.00 <br />(3) Site Plan Rcvinw (commercial only) @ $79.00 <br />(4) Investigation Fee <br />(5) Ralnspection Fee @ $2S.~0 <br />(6) Other inspections not listed above <br /> <br />x$40= -- <br />Total: $__ <br /> <br /> <br />