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F_.QI;H~FFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> ~0 High Street NE <br /> Salem. OR 97301 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />8:C0 e,r~,-4:$0 p.m, Phone 588-5147 Ffe~: J~ ~w~, <br />FAX 588-7948 <br /> <br /> DWELLING/STRUCTURAL AND/OR SEPTIC PERMIT APPLICATION <br />COMPLETE ALt. SECTIONS, 1 THROUGH 4 <br />1. JOia Description <br />R.~g~rrlAL, COMM~RCIAL <br />] New ~ <br /> ] NcwS~w/oga~ge [ ] Rel~a~ [ ] Additi~ [ ] Demo <br /> <br />Site No, <br /> <br />}ntraotor Information !1~ 5. Fee )chedules <br /> Owner Ma{ling Add.si & Phon~ No. A. <br /> ([nclodos El. <br /> <br /> ~e N~ <br /> <br />Septic Information (Check where applicable) <br /> <br />$ig, l~v~luati~ [] <br />DraiMi~ld <br /> <br />I~ininlt No, B~lmeml; New Ins~llation <br /> <br /> Will Call When Test l.lole~ Ready [] <br /> Existing Site Ev~lua[ion No.: <br /> <br />Tank Size: <br /> <br />Ihavo ~ this al~li~tion in its entirety ~d certify that the stated iMorma[ion <br />is ~e s~ co~ ~ the ~[ of my ~owl~e, <br /> <br />faro ~ ~$~te~ bu~derOg [ ] ~ au~or~ ~ms~ative ~ ~ mgis~r~ <br /> builder, ' ' <br /> <br />Wat~ Supply: <br />PfivateWell [ ]~ffprtn$ [ I <br />CommUnity We. Il Ifil City [ I <br /> <br />' Valuation: $ ...... <br /> <br />pplieable) <br /> <br />~, Me, PI ~m separate <br /> <br />(l) Permit Fee <br />(2) 5% Stat~ St~rcharg~ (,0~ x BI) <br />(2> Zonb~g Surcharge (,0~ x BI) <br />(4) Plans Chra3k (.65 X B1) <br /> <br /> = I $$,00 <br />Subtotal,* ~' <br /> <br /> <br />