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ATTACHMENTS
Attach a Site Plan – Drawn to scale with north arrow.
• Show property boundaries, floodway, and floodplain lines.
• Show dimensions of the lot.
• Show dimensions and location of existing and/or proposed development on the site.
• Show areas to be cut and filled.
Attach Statement – describing in detail how each applicable development standard in Sections 17.16.100.15, 16, 17, and
18 will be met.
For New Construction or Substantial Improvement also show:
• Existing and proposed grade elevations adjacent to the walls of the structure done by a Professional Land
Surveyor, Architect, or Engineer.
• Location and elevation of temporary elevation reference marks on the site.
Special Note:
Substantial Improvement is defined as any reconstruction, rehabilitation, addition or other improvement of a
structure, the cost of which equals or exceeds 50 percent of the market value of the structure before the start of
construction of the improvement. Please refer Stayton Municipal Code Section 17.04.100, for more complete
definitions of New Construction and Substantial Improvement.
APPLICANT CERTIFICATION
The applicant understands and agrees that:
• The permit applied for, if granted, is issued on the representations made herein;
• Any permit issued may be revoked because of any breach of representation;
• Once a permit is revoked all work shall cease until the permit is reissued or a new permit is issued;
• Any permit issued on this application will not grant any right or privilege to erect any structure or use any
premises described for any purposes or in any manner prohibited by the ordinances, codes, or regulations of the
municipality;
• The applicant hereby gives consent to the City Planner or other Building Official to enter and inspect activity
covered under the provisions of the Stayton Municipal Code Section 17.16.100;
• If issued, the permit will be posted in a conspicuous place on the premises in plain view; and,
• If issued, the permit will expire if no work is commenced within 180 days of issuance.
I hereby certify that all the statements in, and in the attachments to this application are a true description of the existing
property and the proposed development project.
Owner: _____________________ Date: _______________ Signature:
OR
Authorized Agent: ____________________ Date: _______________ Signature:
(This section to be completed by Planning Department)
Date Received __________ Fee Paid: $_________ Reviewed by: __________
Flooding Source (name of water body.): _________________________________________________________________
AE Zone A1-30 Zone A Zone FRINGE FLOODWAY (_____width of floodplain in A Zone)
Permit # ___________________ Issued by ________________________________ Date _______________________
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