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[ ,FoR'Om?yS 0y Y <br /> Received By~ ~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street 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 /> FO,R OFFICE USE ONLY <br />ICily Setback Requirement,~: <br />I Front: o~ R~; <br />[,~f, Side: O~- ' v~g~, Sit*'.&-- 7 <br /> <br />1. ,lob Description <br /> <br />( [0~ew Single Family DwelLing w/garag~ <br />( ) New Single Family Dwelling w/o garage <br /> <br />( I~G~age, atlached <br />( ) Garage, detached <br /> <br />MARION COUNTY <br />BUILDING I~PECTIOr~ <br /> <br />~t.o'~d0r R~er ( ) <br /> <br />No, Bedrooro. i: ~ <br /> <br />2. Location of Installation J'"¢-/~a/q~ dfc' ~7~'~q <br /> <br />Mobilo Hom~ P~k $~e ~ <br />Sec,on~ ~:Township ~ R=ge ~ Zone ~ Map Wa~rSu~ly: <br /> PfivateWell ( ) Spring ~ <br />LotWid~ '~ ~De~ /~ Acres I.eg.~t ~ Corner ..... fro Commu~lyWell( ) City <br /> <br />3. Contractor Information ........... <br /> <br /> ~I own, c~id~ in, ~ will r~id~ <br /> (.) ~er$~nd that I m~t register as a comtmcfion coa~act~ if ~ s~urc is sold or offered f~ sale ~fora or u~n completion. <br /> (~ will bo m7 own general contralto, <br /> <br />If I hire subcontractors, I will ]fire only subcontractors registered with the Consh'/lglion Contractors Board. If I change my mind and do hire a general cunt r ac,-!c¢ <br />who is regiaterext with the Con~Iruction Contractor s Beard, I will immediately notify Mahon Comay of the na lie of file contracor: <br /> <br /> ( / I am a registered builder OR the authorized representative of a registered btalder, <br /> <br />Maihng Address: I Phone: <br /> <br />4. Fee Schedule <br /> <br />A, New One-and-Two Family Dwelling Code <br /> (i~leudes El, M~, :PI) <br /> <br />(2) 5% Stat* Surcharge (,05 x Al) <br /> <br />(3) Plan Review <br /> <br />Valuation: <br /> <br />= $185.00 <br /> <br />B, Miscellaneous Fees <br /> <br /> (I) Ddveway w/curb @ $7.50 <br /> <br /> (2) Driveway w/o curb @ $I7.00 <br /> <br /> (3) Addit~on~I/?lan Revlewa or Agdend~ros <br /> (4) I~vesdgation Fee <br /> <br /> (5) Reinspection Fee @ $25,00 <br /> <br /> (6) Other l~spections not listed above <br />RECEIPT: <br /> <br />x $40 = __ <br /> <br /> hereby ecrlifylthat the above information is correct and lhat I have read and understand the Information NcaJce to Property Owners about COll~;nugtiOll Responsibilities on the <br /> <br /> $1gnature of Ai,pllean,: ~/.~ff¥../~7'ff~- ~ ~ Dale:- ~--.~ <br /> Site evaluation& septic, eleclrical, pithing and mechanical work req~re serrate ~r~, Check with Matio~ County Bta]dthg I~s~Joa ~fore s~lbn~thng <br />MC 15-80 Rev. 1~2 <br /> <br /> <br />