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MARION COUNTY BUILDING INSPECTION <br /> 220 High Slx~t NE, <br /> Salem, OR 97301 <br /> 8:00am-4:30pm Phone 588-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br />ONE & TWO FAMILY DWELLING PERMIT APPLICATION <br /> <br />COMPLETE AI.L SECTIONS, 1 TItROUGH 4 <br />1. Job D~cription <br /> <br />FOR OFFiCE"~JSE ONLY <br /> <br />( ) New Single Family Dwelling w/garage ( ) Garage, attached <br />(i/o/New Single Family Dwelling w/o garage ( ) Garage, detached <br /> <br />Detached Garage Height: No. Bedrooms: <br />i~oe¢.~:..~.~L io,..~., ...... .~.,.. O~.r, -~ <br /> <br />Location oflnstallatlon ,v/~ -- <br /> <br /> Job Addre~s ' Tax A'cct 'No ' <br /> ,,,, <br /> Me'lc Ilome P~k S~cc ~ <br /> Se*don I Town~Np [D Range ~ Zone .~ Map ...... Water Su~l~' <br /> .... .t ~ivateWelI ( ) Spring <br />~'~id~, ~.~ Lg'~h i~.q~ Acres Meg,~t Corner ~, Commu~tyWell( <br /> <br />3. Contractor Information ....... <br /> <br /> ( ) I own, mqide in, ~ will reside in th*~ompleted s~aurc. <br /> <br />Contractor Busincs~ nam, & #; I Mailing Address: I Phone: <br /> <br />4. Fee Schedule <br /> <br />A, New One-and-'i~vo Fanfily Dwelling Code <br /> (inleedaq El, Me, PI) <br /> <br /> ( ) I am a registered builder OR the m~lhotized representative of it registered builder. <br /> I" <br />Architect name: ~.~4~r. ~.~vx_~f.~Jc~t ... MmhngAddre,s: <br /> <br />(1) Oros~ sq. r. ~'/c~- ~ s 28 <br />(2) 5% Sram Sllrcluuge (.05 x Al) <br /> <br />(3) Plan Review <br /> <br />(4) .9%~llng Surcha~e ($15 lfapp mab e) <br /> <br />.... 23_L0. ~ <br />,-- $i8~.00 <br /> <br />B. Miscellaneous Fec~ <br /> (1) Driveway w/*urb @ $7.50 <br /> <br /> (2) Driveway w/o curb ~ $17.00 <br /> <br /> (3) Additional Plan Reviews orAddendums <br /> <br /> (4) Invesligation Fee <br /> <br /> (5) Reingpeedon Fee @ $25,00 <br /> <br /> (6) Other I?3oe¢~&.n~ not li~ted above <br />uec~n~r :_._0~,'/z; <br /> <br />x$40= <br /> <br /> Ihetebycedf hi, he,boveinformallor~ s¢orrec and <br /> ceve~;, si;d'g oF~is fSm ' ' ' h t Ilia e mad and uaderstand thc Inf~tion N~c, to ~wners a~t Coastal*don Res~nsibil;0es on g,e <br /> <br /> S e evM aQo & sep eqo re ~e~rate ~rn~t& Check wi~ M~ o~ Co n y B~ d ng ]~sl~c~ion ~fore ~ubmilljug this ~plication. <br />MC 15-80 Rev, 1~2 <br /> <br /> <br />