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FOR OFFICE USE ONLY <br /> <br /> ~20 High Street~J~l~ -- <br /> Salem, OR 97~1~1'~ <br /> <br /> 8:00 a.m.-4:30 p.m, Phone 588-5147 <br /> <br /> FAX 588-7948 J.~l~J~lO~ CO,Jr [,,, ' <br /> DWELLING/STRUCTURAL AND/OR <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job Descrlptlon <br /> <br />!~O~I~FFtCE USE ONLY <br /> <br />RI~SIDENTIAL COMMERCIAL <br /> New SFD w/garage [ 'l A¢¢~s~o~ I 1 New [ )Sign <br /> NcwgFD w/o garage [ ] Relocate [ ] Addlt[o~ [ ] Demo <br /> I Addition [ I l~emo [ ] Altera[ion [ ]Other <br /> Alteration [,~4~'Other [ ] Change/Occupancy <br /> <br />installation <br /> <br />~ Addre~"s'" Tax Acct. No. C O~s Street ~(;,e~,'~.0 ~ <br />Suba~vi~ion ~[ 8lock <br />Moblte Home Park Spa~e ~ <br />~c~._s~,~ H~.>~, le ~ ...... <br /> S~tlon Town~hlp Ran~ "'~ae Map W~ler Supply: <br /> <br />~,WJd~ ~tD.~ / Acm* [~g'~Lo[ Com~ PfivatcW*U t ~rJng [ ] <br /> '~' 1~ Community Well [~ City [ ] <br /> <br />retractor Information <br /> <br />Auth, Agent/l-easee <br /> <br /> A. New O~Family Dw~ Yaluatlon: $ <br /> (includc~ ~ Me, <br /> <br /> (]) sq, Ft. ~.2g ~ = <br /> <br /> ( )Ba~fo~lanReview ~ = 185,00 <br /> (~ng SurcMrge ~f Applicable) <br /> <br /> g. 8~mal Pcn)~i~ <br />~emit fee dete~ed b~Muation, <br /> <br />Mailing Adclm,q$ & Phone No. <br />Mailing Address & Phone No. <br /> <br />Contractor Llu~incss Name & Number Mailing AddmsR &- Phon~ No. <br /> <br />Mailing Address & Phone No, <br /> <br /> Architect <br /> <br />4. Septic Information (Check where applicable) <br />.p~l.reop" P r ope ~ ~ No, Bedrooms: Ex[sting No. Bedrooms; New ]~lstallatlon [] <br /> <br />,dy <br /> <br />/information <br />= registered <br /> <br />¢) 5~ State S0~harge (.05 x ~ 1 ) ~ <br />(3) ~ning Su~hargc (.05 x B1) <br />(4) Plans Check (,65 x B l ) ~ <br /> <br />(1) S~uadon i' <br />(2) New S~i~ Pcmit <br />(3) A~th~cc <br />(4) ~ist~tm~ <br /> <br /> Subtotal: $ .... <br /> <br />25.0ll <br />[sted above x $40 = . .... <br /> Total: g <br /> <br /> <br />