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FOR OI*FIC yS.E NLY <br />~,eceivdd By: ~ <br />] Zoning Validation: ~ <br />II)ate: - /-lY-qg <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> ' Salem, OR 97301 <br /> $:00am-4:30pm l~Olle $85-$147 <br /> Codo-A.Phon* 558-7904 <br /> FAX 588-7945 <br /> <br />FOR OFFICE USE ONLY <br /> <br /> ONE & TWO FAMILY DWELLING, PERMIT <br /> <br />1, .lob Description <br /> <br /> (L~ New Single Family Dwelling W/garage (~-5'~Garage, attached <br /> ( ) New Single Family Dwelling w/o garage ( ) Garage, detached <br /> <br />Square Ve~t: B~em~nt: ' [ Main Floor:/fl ~ ~"' I Second Floon <br /> <br />2. Location of Installation <br /> <br />Proper~yOwner b~, ~- ~'~d~$[~,~/4A I MailiflgAOdress gaO~q3 i~7~/Y'/~/~,/[/',e, PhoneNo. J~ I' 7 ~ X ~ <br /> <br />MoMI0 Home Plak S~ ~ <br />Se~ion ~ Town~p ~X R~ge ~ : ,, ~on*,~ Map Wa~;'S~i'~; ........... <br /> <br />L~WJdm~.~ L~m~h qg~/ Acres ~eg,~t~ Comerffd PdvateWell ( ) Spdng ( <br /> Comm~Mty Well ( ) City <br /> <br />3. Contractor Informtion <br /> <br />, Mailiag Addr~ . I Phone No- <br /> <br />own, reside in, or will reside in the completed structure. · <br /> <br />untierstand that I m~t register as a construction oantra~tex if the structure is sold or offere<l/'or sale b~fore or upon completion. <br />will bc my own general contramor. <br /> <br /> ~) I am a regls~red ~ilder OR ~e m~ofi~d re~esen~five of a regls~red ~ld~, ~,~. <br /> <br />4. Fee Schedule <br /> <br />A. New Oae-~nti-Two F~mily Dwelling Code <br /> (inleud~ El. Me, PI) <br /> <br />(l> ~ro. sq. Ft. <br /> <br />(2) $% State Surcharge (.05 xAl) <br /> <br />(3) Piton Review <br /> <br />(4) Zo~fing tiotehtage ($15 if applicable) <br /> <br /> <i> Driveway w/c~b @ $730 <br /> <br /> (2) ~veway w/o e~b ~ $17.~ <br /> <br /> (~) ~fional ~n ReviCw~ or ~dendu~ <br /> <br /> (4) Inw~g~fi~ F~ <br /> <br /> (5) Reins~oa F~ ~ $25.~ <br /> <br /> (6) ~er Ins~fions not lis~ ~ve <br />R~c~m: /~7/ <br /> <br />NameofApplicant(PleaseFrinl): P~ 27a/t/ggFmz-m?~ ~0, L, L, g, ~hon~: <br /> <br /> <br />