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'~ .................................. MARION COUNTY BUILDING INSPECTION <br />FOR CITY USE ONLY COMMUNITY DEVELOPMENT CENTER i FOR CITY USE ONLY <br />R~2,vedBy~'/'~r- I>ate: ~...~ 3150LancasterDr. NE-Suit,eC i oiV, Setbacks' <br />Zonifig By: -~"~Jc~ City~ S~lem, Ore,,on 97305/eI~ ,~ : "" <br />v, ....... ~ 8:00am-4:30pm /~r/~,.~ ! Left.. ~-.~-~R/gh~.~ <br />..................................... 24 hr. Inspection Line 373~d~/(,~ <br /> FAX 588-7948 '~ c,~;~.......~..., <br /> ONE AND TWO FAMILY DWELLING PERMIT APPLICA _T~Oj~, ~' <br /> <br /> Dwelling labels must be obtained at Marion County Building Inspection and must be [Maced It t~r~t~Jf ,to [ns~O~ipn fo]~gg, electrieal and mechanical <br /> <br />1. JOB DESCRIPTION '~ [,dz~, O't~,~ <br /> <br />( ) NewSi~eFarailyDwettingwithAtlacl~Garage <br />( ) New single Family Dwelling with De4ached Garnge <br /> <br />. ,.onofwo..: ½r a e / <br />SquareFootage: Basement: ~/~1 lstFloor:~//~2ndFIoor: <br /> <br />Numher of Bedrooms: .~ Existing: Proposed: <br /> <br />( ) New Duplex with Detached G~ <br /> <br />Occupancy: Cola.st. Type: <br /> <br /> Stories: <br /> <br />Dwelling Height: //~ '* Garage Height: <br /> <br />Parcel Owner: <br /> <br />Suhdivisinn: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Lot: <br /> ~ Pardi S~: AC UGB: XY ( ) N <br /> <br />Property Locator: <br /> <br />Block: <br /> <br />Water Supply: ( ) Private Well <br /> <br />City Sewer X <br />Sep6c System__ <br /> <br />( ) Community Well O~City <br /> <br />3. CONTRACTOR INIORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />() <br /> <br />I am the PROPERTY OWNER and o~, reside m, or will r~side in the completed slruetare and will he my own genial conlmctor. I und~sland that I must register <br />as a construction contractor if the structure is sold or offered fix sale befor~ or upon completion, lfl hire subcontractors, I will hire only snboontraetors rngist~r~d with <br />the Construct/on Contractors Board. Ill change my mind and do hire a general contractor who is registered with the Construction Conmmtr~ Board, I will <br />immediately notify Marion County of the name of the contractor. <br /> <br />() <br /> <br />I am the AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Business Name (please print) <br /> <br />Mailing Address: <br /> <br /> Street City <br /> (~)'~ I max a CONTRACTOR registered with the State of ~g~. <br /> <br /> Ci~' <br />4. FEE~ <br /> <br /> V~UAT1ON (S~ Valmtion Sable to d~me ~e val~tion ~ on ~ua~ <br /> ~g~) <br /> Liv~g~ Squ~eF~ x $~.66 = $ <br /> O~Squ~F~t ~ x $16.27 $ ~ <br /> <br /> Bulldog ~ $0.185 ~ ~uare f~t <br /> El~i~l ~ $0.090 ~ ~uam ~t <br /> M~i~ ~ ~.040 ~ ~m ~t <br /> Plm~g ~ $0.0~ ~ ~uare <br /> <br /> 2, H~ ~iew Fee <br /> <br />Zip Phone <br />~'- Registration#: q/~--~ 74 <br />q7357 7dq-.,Y. ff ? 4/37 <br /> <br />Zip Phone Fax <br /> <br />B. Fe~ Summary <br /> (1) permit Fee (A-I) <br /> (2) Stale Surcharge (.05% x A.I) <br /> (3) Pl~ Revi~ F~ (A-2) <br /> (4) ~iti~ PI~ ~i~/~m ~ $50~, <br /> m~imum o~lfh~r. <br /> (4) Z~i Surc~, if a~li~lc ($30.~) <br /> (5) lnvesti~tion F~ ($.4050 ~ ~. fl.) <br /> (6) ~ F~, $50.00 <br /> (7) lns~o~ ~ ou~ide ofn~ <br /> busi~ h~m, $50~, m~um ~ hou~ <br /> (8) l~s ~ whi~ no ~ is s~ffi~ly <br /> ~t~, $50.00~, ~imm ~e h~r <br /> (10) Fou~ti~ ~y Au~fion, $25.00 <br /> <br /> -- <br /> xo~ <br /> <br />I h~eby c~ify that the above information is correct. Permits__a..a..a..a..a..a.~on-m~n~nable and ~ ifw~k is not s~ttlgl wjth'.m 180 da~ of issualtce or if v/ork is ~sspk*ad~ for 180 days. <br /> Name of Applieam [Please Printl: ~ <br /> <br /> Phone: <br />Siguatur~ o f Applicanl: -- ~ ~. Date: t~-~- ~ Mc l~.ao ~a <br /> <br /> <br />