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FOR OFEICE USE ONLY <br /> <br /> - .......... <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Sa)em, OR 97301 <br /> <br />a.m..4:$0 p.m. Phene 58~,-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 />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. Job Description <br /> <br />I~.I*.SIDEN'FIAL <br /> New SFD w/garag~J <br /> New SI;I) w/o garage <br /> Additiorl <br /> Alteration <br /> <br />l~.~locate <br />Demo <br />Other <br /> <br />COMMERCIAL <br />[ ] New [ ] Sigt~ <br />[ ] Addition [ ] Demo <br />[ I Alteration [ ] Other <br />[ ] Change/Occupancy <br /> <br />2. Location of Installation <br />Lot Wi~'th~ / '" Prkvate Well [ ] Spring i ] <br /> <br />3. Contractor Information <br />Property Ow~/¢~ _.~ Mailing Address & Phone No. <br /> <br />,¢¢ltracu)t l~t~sincss Name & ~tlmber Mailit~g Addms~ & Phone No. <br />A~'chi~cet Mailbg Addrc5~ & Phone No. <br /> <br />4. Septic information (Check where applicable) <br /> <br />l;xisthlg Sil~ Evaluation [] ~'~xis~ing Site EvaltlaIlon No.: / <br /> <br />¢,¢¢have t~ad this applicati~ in its entirety and ce~ify that the stated infon~ation <br />]~ pedom~b~g work on a property I own or ~cupy. <br /> <br /> agree {o [>uiid acm,'di,l~t~ ~c sub[It,d plans ~nd specifi~atlol~s the laws of <br /> <br />5. Fee Schedules <br /> <br />A. New One-and-'l'wo Family Dwelling Code Vah~atlot~: $.__ <br /> (includes RI, <br /> <br />(1) Sq. Pt. __,,,_ x .28 - -- <br />(2) 5~70 State Surcharge (.05 x Al) = -- <br />(3) Base Fee for Plan Review = 1 <br />(4) 7x'~lblg Surcharge (If Applicable) <br /> Sul>total: $ .... <br /> <br /> (Per~'~[~ fcc detcnnlned t~y valttatlon. ; <br /> iii. Me. PI are separate permits.) Valuatth~: $ _~/:~ <br /> <br /> (I) P~it Fcc <br /> (2) 5% State Surcharge (,05 x B 1) ~- ~ ~ I <br /> <br /> (4) Plan~ Ch*ok (,65 <br /> <br /> DEQ Surcharge) <br /> <br />~0) Aa~ori~lim Notice (4) Exlaing System Repoa <br /> (5) Major Rei~ir <br /> Mitloe Re.ir (tank oily) <br /> <br />(1) Driveway w/curb@ $7.50 <br />(2) Driveway w/o curb @ $17,00 <br />(3) Site Plan Review (commercial o~/ly) @ $79.lX) <br />(4) Investigatiol Fee <br />(5) R¢in~peciion Fee @ $25,00 <br />(6) O~her inspccdotls not listed above <br /> <br />--_ x 54(I <br /> Tot,d: <br /> <br /> <br />