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FOR OFF~CE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br />S::O0 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 /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOD Description <br /> <br /> RI%SIDEN'HAL COMMERCIAI, <br /> <br /> [ ] New SFD ~[ogarage [ ] Relocate [ ] Addition [ ] Demo <br /> [. l~'ddk>. [ ] Demo I I Aheratlon [ ] Othm' <br /> {kwFAlleratlon [ ] Other [ ] ChangctOcc0panc~ <br /> <br />2. Location of Installation <br /> <br />lob ~dd~¢~ ..... ,~ ~tS~/P ' ~/O 't's St et " <br />Mobile Borne Park Spa~ <br />', ,~ ~ ~0 ,- / ~'"~ Come~O Private W<,U r ] <br /> <br />L Contractor Information <br />l>rqpcr~y Owqcr Mailing Addrcs~ & Phone No -~(~-~ <br /> <br /> Mail~)g Address & I'hon~ No <br /> <br />ltractor Bu~hles~ Name & Numar Mailing Addrcs~ & Phcal¢ No <br /> Mail~lg Addre~ & Phone No <br /> <br />4. Septic Information (Check where applicable) <br /> <br /> Proposed No Bedrooms:: T'xlsthng NO, ])edrooms:: New lnsrallation <br /> <br /> 3est llole~ Ready [] Will Call When 'Ie~t Iloles Ready <br /> <br />~J f ha~¢ read thi~ application in its enurct5 a0d comfy that lJl~ stated informmon <br /> <br /> builder <br /> <br />[ J ()diet__ __ <br /> <br />agree to build according to lhe ~ubmittcd plum and spec[ficatioas, lh~ ]a~ o~ <br /> <br /> 5. Fee Schedules <br />t A New One-and-T~o Family Dw'elling Code ~ahtatlon: $.__ <br /> <br />(includes El. Me. PI) <br /> <br />(l)Sq Ft x 28 =__ <br />(2) 5% State %l'~..harge (05 x At) = _ <br />(3) Base fee for Plan Review =., ,! 8~.00 <br />(4) Zoning SntcEarge (If Apph~able) = <br /> Subtotal: $ .... <br /> <br />(I) Permit F¢~ <br />(2) $% Stare Surcharge (g$ x B1) <br />(3) 7~ning Surcharge ( 05 x BI) <br />(4) Phns Cheek (65 × BI) <br /> <br />Subtotal:: <br /> <br />Septic Fees (Includes DEQ Surcharge) <br />(1) Sim Evaluation <br />(2) Ne~ Septic IngtaI[atic~ Permit <br />(3) Authorizatin~ Noucc <br />(4) Ex~sting S~stem Report <br />(5) Major Repair <br /> Minor Repair (tank only) <br /> <br />--,-- x $41) = <br /> Total;; $ ~'"~ <br /> <br />(1) Dt~,eway vi/ralrb @ $750 <br />(2) Driveway w/e cud~ @ $17 O0 <br />(3) Site Plan Review (¢ommemial only) @ $79(~ <br /> <br />(5) Rem~pcction ~e @ $2500 <br />(6) Oth~-mspecuons not h~ted above <br /> <br />Recelpt: ~..~ ~ 7A <br /> <br /> <br />