January 2019
CITY OF STAYTON
A
PPLICATION TO CHANGE THE USE OF AN EXISTING BUILDING
PROPERTY OWNER:
Address:
City/State/Zip:
Phone: ( ) - Email:
APPLICANT:
Address:
City/State/Zip:
Phone: ( ) - Email:
LOCATION: Identify the exact location of the property: Street Address:
Assessor's Tax Lot Number: Map 91W Lot
Closest Intersecting Streets:
DESCRIPTION OF PREVIOUS USE.
DESCRIPTION OF PROPOSED USE.
Gross floor area to be occupied by the proposed use: _______________________
Is the Proposed Use the only use of the property? Yes No
Are any exterior changes to the building proposed? Yes No
Has this property received site plan review approval or conditional use approval, or some other land use approval from
the City of Stayton?
Yes No If yes, year approval received_____________________
I understand that the Change of Use permit application fee of $25.00 is non-refundable. I hereby certify that all
information provided in this application is correct. I understand that a permit from Marion County may also be
required and that a City of Stayton permit does not take the place of a Marion County permit. I understand it is my
responsibility to contact Marion County Building Inspection (503-588-5147) to determine if other permits are
necessary.
Date: Signed: __________________________________________
Signature of Applicant
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DO NOT WRITE BELOW THIS LINE
Application received by: Date: Fee Paid: $ Receipt No.
Permit through Marion County Building Inspection required yes no
Action of City Planner: Approved Approved with following conditions Denied for failure to meet the Code
Sections noted below
__________________________________________
City Planner
