Structural Permit Application.pdf

STRUCTURAL Permit Application Malheur County Building Department 14 South 3rd St. I P.O. Box 2783 Nyssa, OR. 97913 Phone: 541-372-5460 Fax 541-372-5465 Email: BuildingDepartment@bldgmalheurco.org

DEPARTMENT USE ONLY

Date App Rec'd_____

Th. d d OAR 918 460 0030 P f k. ,s permit 1s issue un er - - errmts expires I wor 1s not commenc ed with 180 days of issuance or if work is suspended for 180 days.

TYPE OF WORK (Check Box) LOCAL GOVERNMENT APPROVALS

PLANNING & ZONING 0 New Const O Addition O Alteration O Repair

0 Tenant Improvement O Solar O Other REF# CATEGORY OF CONSTRUCTION (Check Box)

Use Zone: T S,R s TL

P/ZPermit# Date [ssued 0 1 & 2 Family Dwelling O Manufactured Dwelling O Accessory Bldg O Commercial O Industrial O Multi-Family

Setbacks: Road ROW: L.side R.side Rear --- -- -- --- **Owner/Contractor responsible to meet above setback requirements

JOBSITE INFORMATION AND LOCATION

Jobsite Address:

Ste/ Apt/SP#: City: OR. Zip:

Job site Business Name/ Tenant:

Farm Dwelling: New 0 Replacement O Non-Farm Dwelling: New 0 Replacement O Other: 0 Description:

Cross St & Directions to Jobsite: Flood Plain: Yes O NoQ Required Elevation:

Signature: Title:

DETAILED DESCRIPTION OF WORK

Print Name: Date:

SANITATION

Sanitation Required: Yes O No 0

PROPERTY OWNER INFORMATION

Information Verified: YesO No 0 Print Name: Signature: Title:

Mailing Address: Print Name: Date:

City: ST: Zip: (l)FEE SCHEDULE - Valuation information (Dept Use Only)

Phone: Cell:

(a) l & 2 FAMILY DEWLLING: (b) COMMERCIAL:

tn1s msta11at1on 1s bemg macte on res1ctent1a1 property ownect by me. 1 ms property 1s New Dwelling: Sq Ft New Bldg Sq Ft not intended for sale,exchange, lease or rent. OAR 70 I.OJ 0. Att'd garage/carport Sq Ft Existing Bldg Sq Ft Owner Signature: Covered Porches Sq Ft Addition to Bldg Sq Ft Print Name: Date: Deck Sq Ft Number of Stories

CONTRACTOR INFORMATION Dwelling Addition Sq Ft Construction Type Business Name: Other Structures Sq Ft Occupancy Group Contact Person: Construction Type Occ. New Address: Occupancy Occ. Existing City: ST: Zip: Valuation: $ Valuation:$ Phone: Cell: PERMIT FEES

Fax: Email:

CCB Lie# MDULSILic# Authorized

(2) BUILDING FEES

(a) Permit fee $

(b) lnvestigave fee $ Signature required: (c) Re-inspect/Special inspect. ($65.00 per Hr) $

Print Name: Date: (3) PLAN REVIEW FEES

(d) Enter 12% surcharge (.12 x (a) and/or (b), I hereby acknowledge that [ have read this application, that the information given is (c) if applicable) $ correct, that I am registered with the State Construction Contractor's Board ( or that I am exempt under the provisions of ORS 701), that I am the owner or authorized agent of the own�r, that the registration No is correct and current, that the plans submitted are in

(e) Plan review fee 65% above(a) ifrequired $

(t) Fire & life Safety Fee 40% of(a)ifrequired $ compliance with state law. Manufactured Dwelling Foun_dation installers must have an Oregon MDI/LSI/LI license Total Permit Fee Due (A) thru (F) $

ERIC EVANS

Planning Director