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FOR OFFICE USE ONLY <br /> <br />MARION COUNTY BUIL~'Bcl~I. G4N,~3E,t~TI01~ <br />220 High Str,~e~'~lE. <br /> Salem OR 9~'~)1 <br /> <br /> Code-A-Phone <br /> FAX 588-7948 <br /> <br />F~ OFFICE USE ONLY <br /> <br />COMPLETE ALL SECTIONS, i THROUGH 4 <br />1. Job Description <br /> <br />RESIDENTIAL COMMI~,J~,CIAL <br />[ ] NewSrD wi garage [ ] Accelso~y [ ] Ne,~ [ ] Sign <br />j ] NewSFDw/ogarage [ ] Relocate [ I Additiot~ [ ] Demo <br />I ] Addition I ] Demo tX] Alteration [ I Oth*r <br />L ] al;eranon [ ] Other [ ] Change/Occupancy <br /> <br />2. Location of installation <br /> <br />,lob A(klres~ 'la~ Acct, No Cross $~rcet <br /> 8724 Golf Club Road,,, SE 60455-30 Hiqtlway 22 <br /> Site No, <br /> A~!]sville, OR 97325 <br /> N.A. N.A. N.~. <br /> N,:A. N.A. <br /> Townshi" I Rani~ '7~ Map <br /> <br />J. Contractor Information <br />property (')'~ner Mailing Address & Phone No, <br /> <br />Tcra& Shirley Becket 12444 W. <br /> <br />N.A. ,f 503) 769-3304 <br /> <br />4. Septic Information (Check where applicable) <br /> <br />L~xtstin§ Dramfinld Length:: 1, ~0 f~. Tank S/ge;; 5,000 ~1. <br />Date Tmxk last Pumped ~ 199] <br /> <br />5. Fee Schedules <br /> <br />I ] [ agree to binld according tOJhe submiued plan~l~pecffigations, thc law s of t <br /> <br />B <br /> <br />C <br /> <br />D <br /> <br />A New Ooe-and-Two Family Dwelling Code Vahtallon; $__ <br /> (includes El, Me, PI) <br /> <br />(l)Sq Ft ----x 28 = . <br />(2) 5% StaTe Sumharge ( 05 x Al) <br />(%) Bas~ Fee for Plm'~ Rew~w I db.()0 <br />(4) Zoning Surcharge (If Applicable) <br /> SoDlotal: $ <br /> <br />(I) permit <br />(2) 5% State Sorvharge (05 x Bi) <br />(3) Z~ning Surcharge (05 x BI) <br />(4) Plans Cheek ( 65 x B1) <br /> <br />Septic Fees (Includes DEQ Surcharge) <br />(1) Site l~aluatlon <br />(2) New Septic In~tatlahon Permit <br />O) Aulhofization Notice <br />(4) Ex~sting System Rcpor~ <br />(5) Major Repair <br /> Mblor Repair (tank only) <br /> <br />Valuation:: <br /> <br />(l) Dd'~e~ ay '.~/cnrb (f_3 $750 <br />(2) Dfivewa~ w/b curb (~ $17 O0 <br />(3) Site Plan Review (c~memial ~ly) ~ $79 ~ <br />(4) In~eMigation Fe~ <br /> <br />.... x$40= qotah <br /> <br /> <br />