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i~/~1~ i~O[:~YJ~ UI LD1N G INSPECTION <br /> <br /> lem, OR 97301 <br /> <br /> Code-A-Phone ~8.7904 <br /> FAX 588-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />Left Sider ~ / I RlOIIt Side~ ,~- / <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Job Description <br /> <br />RESIDENTIAI, <br /> New SI;t) wi garage <br /> New SFD ~v/o garage <br /> Addition <br /> Alteration <br /> <br /> COMMERCIAL <br />I Accessory [ ] New [ ] Sign <br />] Relocate [ ] Addition [ ] Demo <br />] Demo [ ] Alteration [ ] Other <br />] Other [ I Change/Occupancy <br /> <br />2. Location of Installation - o ¢r~ ~, <br /> <br /> T~x~ Aec[, No, Cross Street <br />Subdivision ~~ gloc~ <br />Mobil0 Ilome Park Space ~ <br /> Townsh?~ R~;~ct~ ' e . Water Supply: <br />~[WidT¢~ ~tDcp~ Aere~ I~g.l~t Co~ PfivateWea [ ] Spring [ ] <br />· ~ ~ 5 ~O ~ Community We [ ] City [~ <br /> <br />3. Contractor Information 5. Fee Schedules <br /> <br />Mailin~Address & Phone No. <br /> <br />Ma[lingll' Address & Phone No, <br /> <br /> Contractor Ilu~ine~s Nam~ & Number Mailing Address & Phone No, <br /> Architect Mailing Address & Phone No, <br /> <br />4. Septic Information (Check where applicable) <br /> PrOposed No. Bcdroomsr ~f/ Existing No, Sedrooma~ New bl~lallation [] <br /> <br /> 'lEst Holes Ready [] Will Call Whorl Teat I[olel Ready [] <br /> Existlng Site Evainatic~l [] Exlsd,,g Site Evalualion No.: / q t~ 6 ~.f/. <br /> <br /> ~J"J }lave mad this application in its entirety and certify that the stated information <br /> is true and correct to thc best of my knowledge. <br />[~'Q~am pcr£onning work on a p~peRy I own or <br />[ ] I am a regi~ler~ build0r OR [ ] {he au~ori~d rc~msenlativc <br /> builder, <br />I~,e wo~ will be peffom~ea by a registered buQ~r, <br />[ ] Olher~ <br /> <br />Signature of Applic~_~ ~ / q g ~ ~ <br /> <br /> / <br /> <br />NewO e-and-TwolCamilyDwe tlgCode Vathailon: $ ,, <br />([oclude~ El, Me, P1) <br /> <br />(I) Sq, Ft. x ,28 <br />(2) 5% State Surcharge (.OS x Al) <br />(3) Base Fee :[or Plan Review <br />(4) Zoning Surcharge (If Applicable) <br /> <br />(Pemfi'~ fee dct~emin~d by '~alua*ion, <br />El, Me, PI am separdte pennits,) <br /> <br />(1) p~rmit Fee <br />(2) 5% State. Surcharge (,05 x B 1 ) <br />(3) Zoning Surcharge (.(15 x Bi) <br />(4) Plans Check (,65 x BI) <br /> <br />Septic Feea (includes DEQ Surcharge) <br />(1) Site Evaluation <br />(2) New Septic hlsh~llation Permti <br />(3) AuthorizatiOn Notice <br />(4) 'Existing System Report <br />(5) Major Repair <br /> Mino~ R~palr (tank c~ly) <br /> <br />Subtotal: $__ <br /> <br />185.0L~ <br /> <br />Subtotal; $~L~-~ I <br /> <br />Miscellaneous Fees ~ ~ I~-'[ <br />(1) Driveway w/curb @ $7.50 <br />(2) Driveway w/o curb @ $17,00 <br />(3) Site Plan Review (commercial coty) @ $79.~0 <br />(4) Illveafigatlotl Fee <br />(5) Reinspection Fee @ $25.00 <br />(6) Other inspections not listed above <br /> <br />Torah $ <br /> <br />Receipt: /~-~ <br /> <br /> <br />