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FOR OFFICE USE ONLy MARION COUNTY BUILDING INSPECTION FOR OFFICE USE ONLY <br /> _~.~ (~.~, 220 High Street NE city Setb~k Requlr~r'non[!~:: <br /> Ro~ived S?::. ~,~ Salem OR 97301 <br /> <br /> c~yT~ln~w0,~ ~ ~ '-- 800am-4::~pm Phone588-5147 Front /~ / R~r /~ / <br /> <br /> --' FAX 588-7948 <br /> <br /> DWELLING/STRUCT~AL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, I THROUG~] ~ ~ ~ ~ <br /> <br />2. Location of Installation <br /> <br />Subd[vlsion ' ~ ~t B~ock <br />"Mci)do ~e Park Space ~"' <br /> , Range ] <br /> s,~,,, 25- 'r'ow,,~,;~ ~5 ~& ~M ~v <br /> ' PrivazeWe~ [ ] Sp*~r~g [ <br /> <br />/ <br /> <br />3. Contractor Information <br /> <br /> Property wner · Maihng Add.ss & phone No <br /> Auth Agen )i~a$cc ] MaH~g Address dPhone No ~ 7 <br /> <br />Business Name & Numar Mailing Address & Ph~le No <br /> <br />4. Septic Information (Check where applicable) <br /> <br /> le~t Holes Ready [] Will Call When Te,qt Holes Ready [] <br /> <br />IM I ha~e read thts applzcation ill lis entirety and ccrtif) that thc stated tnformatiorl <br />[ I Other, <br /> <br />5. Fee Schedules <br /> <br />A, New One-and-Two Fanffly Dwelling Code Valuation! $.__ <br /> (includes El, Me, PI) <br /> <br />(l)Sq Ft__x 28 =__ ..... <br />(2) 5% State Snrq.harge (OS x At) <br />(3) Base r,e¢ tor Plan Review 185.00 <br />(4) Zoning Surcharge 0f Apphcable) <br /> = <br /> <br /> Subtotal <br /> <br />B <br /> <br />D <br /> <br />Structural Purmit <br />(Permit fee determined by wduation <br />El, Me, P] arc separate permits } Valuatlon; <br /> <br />(1) Permit F¢~ =..~'~:'. ~-O <br />rS) 5% State Surohargc (05 x BI) · <br /> <br />(4) PIa, s Chcc~ (('L$ × BD ¢ ;.'.'2~-. <br /> Subtotal; $ <br /> <br />Septic Fees (Ineludc~ DEQ Surcharge) <br />(1) Site Evaluation <br />(2) New Septic InstaQabon Pemfir <br />(3) Authorization Notice <br />(4) Existing System Report <br />(3) Major Repair <br /> Minor R~ir (tank ~1~) <br /> <br />O) Driveway ,~] curb @ $'/50 <br />('2) Dri*eway w/o curl> ~. $I7 O0 <br />(3) Site Plan Review (commercial only) @ $7900 <br />(4) [n~estigation 14ee <br />(5) Remspectio~ Fee @ $25 O0 <br /> <br />$40 = <br /> <br /> <br />