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FOR OFFgCE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br />8;00 a,m,-4:80 p.m. Phone 588-5147 <br />Code-A.Phone $88-7904 <br /> FAX 588-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />Fro~t: ~1 II Rear: ,.~ # <br /> <br /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Job Description <br /> <br /> RL"SI!."SI~, ENTIAL , <br /> [ ~ ~xcwSFD w/garage [ ] Accessory <br /> [ ]NewS}q)w/o garage [ ] Relocate <br /> [ I Addition [ I Demo <br /> [ I Alteration [ I Other <br /> <br />2. Location of Installation <br /> <br />COMMERCIAL <br />[ I N~w [ ] Sign <br />[ 1 Addition [ ] Demo <br />[ ] Alteratioo I ] Other <br />[ ] Change/Occupancy <br /> <br /> Mobile l lome Park S~ice O <br /> Secti,~ Tow,,~hlp ~X Range~ 7~ne~ ~, Map WaterSupply: <br />~ ' ' ' e~ PeivateW¢~ [ ] Spring <br /> lx>t Wi,kb ~ ~1 Dc~¢ /~O Aare~ I I~g, ~O C°m O Communky Well [ ] City <br /> <br />3. Contractor Intormation <br />'ncr ,,~,. Mailing Address & Phone No. "~q <br /> <br /> 'Mai' g aa~,&~h~ <br /> <br />4. Septic Information (Check where applicable) <br /> <br />'l'e*t I[oles Ready [] Will Can When 'l'es~ lloles Ready [] <br />I~xlsting Site Evaluation [] F,x isling Site F, va~:i '}~''\, <br />i'"opos0d Installation l:'emllt [] , q~?' "x.':,' %',,79 <br /> <br /> '7) ~Xv <br /> have mad th[s applimd~ in it~ entirety ~d'~ the slaled info~ktinn <br /> i~ tree and co.ct to the best of my know~ <br /> <br />5. Fee Schedules <br /> <br />A, New One-and-Two Family Dwelthrg Code Valuathm: <br /> (includes El, Me, PI) <br /> <br /> d)sq. Ft./~¢ · .~s <br /> (2) 5% Slate Surcharge (,05 x Al) = <br /> (3) Base Fee for Plan Rcvinw = _],,_85,00 <br /> (4) Zoning Surcharge (If Applinable)~.'~j.,.~. <br /> ~ Subtotak =$~--5'~, ~ <br />B. Structural <br /> <br /> (1) p~rmit Fee <br /> (2) 5% State Surcharge (.05 x B 1) <br /> (3) Zoning Surcharge (,05 x B1) <br /> (4) Plato Check (,65 x gl) <br /> <br />Septic Fees (Include~ D[iQ Surcharge) <br />(1) Site Evaluat[m~ <br />(2) New Septic Installation Permk <br />(3) Authorization Notice <br />(4) ;Existing Syste. m Repo~ <br />(5) Major Repair <br /> Minor Repair (tank only) <br /> <br />Subtotal: <br /> <br />Miscellaneous Fees <br />(1) Driveway w/curb @ $7,50 <br />(2) Driveway w/o curb @ $17,00 <br />(3) Site Plan R~vinw (commercial only)@ ,$79,00 <br />(4) lnv~'stigati(m Fee <br />(5) Reinspeeticm Fee @ $25,00 <br />(6) Other inspeC, lom not lismd abOve <br /> <br />__x$40= <br /> <br /> <br />