City of Independence forms are now available to complete online for your convenience.
Online forms can be filled out and submitted directly through our website or connected online portals, helping to reduce processing time and paperwork.

Some forms may still be available as downloadable documents that can be completed and returned as instructed on the form. As we continue transitioning more services to fully digital formats, additional forms will be added to our online system.

If you are unable to complete a form online or require a paper copy, please contact us by email and we will be happy to provide one.

Payments can be made at this time by calling 503-838-1212 or stopping by City Hall during open office hours of Monday – Thursday 7:30 am – 5:30 pm (closed holidays). IPD open hours are Monday – Friday 8:00 am – 5:00 pm (closed from 11:30 – 12:30 for lunch and holidays) You can also mail a check written to ‘City of Independence’ to 555 S. Main St. P.O. Box 7, Independence OR. 97351 (we will not process your application until check is received).

What permit do I need?

Describe your project in your own words and we’ll suggest permits you may need.

What is your project?

Search permits

A $35 fee is required for this permit.

Payments can be made by phone at 503-838-1212 or in person at City Hall, located at 555 S. Main Street, Independence, OR 97351. City Hall hours are Monday through Thursday, 7:30 a.m. to 5:30 p.m., and closed on holidays.

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URL

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Form Type

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Approval Status

Project Address(Required)

Owner or Applicant

Name(Required)

First Last

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Homeowner will be installing fence?(Required)

Yes

Contactor

All contractors and subcontractors are required to be licensed with the Oregon Construction Contractors Board under provisions of ORS 701.

Business Name(Required)

CCB Number(Required)

Mailing Address

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Fence Description

Fence Material(Required)

Fence Height(Required)

Other Fence Material

Please specify what type of material your fence will be.

Fence Location

Front yard

Side yard

Back yard

Adjacent to alley

Corner lot

Other location (please specify)

Other Fence Location

Will the fence replace an existing fence?

Yes

Required Submittals & File Upload

Required Submittal List(Required)

A complete application.

A proposed site plan showing the location of the fence in relation to your property lines.

Any special details about the construction/installation of the fence.

A $35 fee for the permit (please call City Hall to make a payment: 503-838-1212)

Fence File Upload(Required)

Drop files here or

Max. file size: 50 MB.

Fence Permit Requirements

Please review the following rules before submitting your application:

All fences must be located entirely on your property. Fences within the City right-of-way are not allowed. The City cannot assist in determining property lines.
Applicants are required to call 811 for utility locates prior to construction.
Fence Heights
1. Fences must meet all vision-clearance requirements at streets and alleys (IDC 74.005(C)).
2. In the front yards of residential uses, fences cannot exceed 3.5 feet in height unless constructed of non-sight-obscuring material.
3. Fences enclosing residential uses cannot exceed 7 feet in height.
4. Fences enclosing commercial or industrial uses must be at least 8 feet tall if topped with barbed wire or other injurious material.
Fence Materials
1. Fences shall be made of wood, brick, vinyl, or wrought iron. Chain-link, sheet metal, metal roofing, plywood, and similar materials are not allowed.
2. Fences must be painted if made of stained or discolored materials.
3. The finished side of the fence must face outward.
4. Fences must be maintained in an upright, self-standing condition and repaired with the same or similar materials used in the existing fence.
Construction of fences must meet all applicable State and local codes.
Once the fence is installed, the applicant must call the City to schedule an inspection.

Fence height and vision clearance illustrated diagram showing A: max 84” fence height for side and rear yards, B: max 42” fence height in vision clearance areas, C: max 42” fence height in front yards.

Confirmation

Consent(Required)

I certify that the information submitted is true, and I have read the standards of this application. By signing, I additionally take responsibility for any work that is not done in accordance with the standards for fences in the Independence Development Code, and will pay to move any fence that is inadvertently built in a public right-of-way and/or compensate the City or any impacted service provider for damage that is done to utilities during the installation of the fence.

Signature(Required)

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Type of Installation:(Required)

New Installation

Relocation/Removal

Other (please specify below)

Other - Please Specify

Date Requested(Required)

Please allow at least ONE WEEK in advance

Applicant Information

Name(Required)

Phone(Required)

Permit Number(Required)

Billing Address(Required)

Street Address City State ZIP Code

Water Meter Information

Property Address(Required)

Type of Building:(Required)

Residential

Commercial/Industrial

Duplex

Triplex

Number of Meters(Required)

Size of Meter(Required)

Size of Multiple Meters Needed

Please list the size of meters and quantity of each you need if requesting multiple.

*Please Note: All water meters come with a sewer connection fee for EACH meter. While under construction there will be a charge for water and water usage. After the home, has had its final inspection, the services will then be charged the full base rate for water, sewer, storm ERU’s and water usage. I agree to comply with all the City of Independence regulations and governing codes. I also agree that if my bill is NOT paid during or after construction, my services will be turned off and I agree to pay all fees and pass due amounts before getting my services turned back on.

Signature(Required)

Date(Required)

A project fee is required for this permit.

Payments can be made by check written to 'City of Independence' and mailed to 555 S. Main St. P.O. Box 7, Independence OR. 97351. Please put in the subject line the address and what the payment is for.

Construction Work Hours:

Residential Zoned Property: Monday - Friday 7:00 am to 6:00 pm No work on Saturday, Sunday, or Holiday

Commercial/Industrial Zoned Property: Monday - Friday 7:00 am - 7:00 pm No work on Saturday, Sunday, or Holiday

NOTE: Permission to work outside of hours listed above must be requested in writing at least 96 hours in
advance and approved by the Public Works Director.

No noise originating from construction vehicles, personal vehicles, construction activities, demolition,
and/or grading outside of hours listed above, and any time on Saturday, Sunday or Holiday without the
written consent of the Building Official or Public Works Director will be subject to citation.

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Applicant's Section - Please complete items 1-7

Permit Number

Parcel Number

Name of Project(Required)

Owner/Developer(Required)

Engineer(Required)

Contractor(Required)

Project Contact Person(Required)

Contact Person Phone Number(Required)

Plan Review Fee

Estimated Construction Cost(Required)

Date(Required)

Month

Day

Year

Plan Check Fee (1%)(Required)

Total Payment(Required)

Check Number(Required)

Residential Zoned Property Monday - Friday: 7:00 am to 6:00 pm No work on Saturday, Sunday, or Holiday Commercial/Industrial Zoned Property Monday - Friday: 7:00 am to 7:00 pm No work on Saturday, Sunday, or Holiday NOTE: Permission to work outside of hours listed above must be requested in writing at least 96 hours in advance and approved by the Public Works Director. No noise originating from construction vehicles, personal vehicles, construction activities, demolition, and/or grading outside of hours listed above, and any time on Saturday, Sunday or Holiday without the written consent of the Building Official or Public Works Director will be subjected to citation.

I, (owner) do hereby agree by my signature below to the preliminary fee as stated above for the plan review fee knowing said fee is based upon the preliminary cost estimate as stated and is subject to change and hereby agree that a response on the above mentioned project may not be verbally or in writing by the Public Works Department until 10 days from the signature date by the owner or his authorized agent. I further agree to comply with the above description plans and specifications as herewith approved by the Public Works Department and also with all rules, regulations, ordinances and resolutions pertaining to construction within public right-of-way and/or dedicated easements.

Signature(Required)

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Requestor Information

An address to an accessory building (ADU) or vacant lot will not be allowed, unless special conditions warrant the issuing of an address.

Name(Required)

Address(Required)

Phone Number(Required)

Are you the owner of the property and the one requesting a site address change?

Yes

Owner Information - If different

Name(Required)

Address(Required)

Phone Number(Required)

Owner Signature - If different than requestor.(Required)

Date(Required)

Month

Day

Year

Property Description

Tax Lot(s)(Required)

If a structure is currently on the parcel, the street on which the main enterance faces:

Reason for Address

Explain in detail the intended use, development or re-development of the property, and the reason the address is needed.(Required)

Requestor Signature

I certify that the information submitted is true

Signature(Required)

Date(Required)

Month

Day

Year

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Your Information

Name(Required)

Address(Required)

Phone(Required)

Landlord's Information

Landlord's Name(Required)

Landlords Phone(Required)

Landlord's Address

If your rental unit experiences any of the following violations your landlord may be required by law to remedy the problem. Be sure to report all violations to your landlord, in writing, at least 10 days prior to reporting them to the city (attach copy of letter). The following are statements that summarize different Independence Municipal Codes, which can be found at www.ci.independence.or.us. These codes should be reviewed prior to completing this form. Provisions of ORS 90.320 may also apply. Please note that this form is not a substitute for legal advice. For a complete understanding of your legal rights and responsibilities, please contact an attorney.

After reviewing the listed city code, check the box below if you believe your residence may have any of these violations:

Unsafe Structural Conditions?

Stairs leading to your residence are not safe to walk on. (IMC 6-114)

Stair and balcony railings are not strong and stable. (IMC 6-115)

Floors, balcony, and/or deck are not safe to walk on, broken or deteriorated. (IMC 6-112)

Residence has a ceiling sagging or falling in. (IMC 6-118(a))

Roof has defects that might admit rain. (IMC 6-110)

Residence does not have adequate roof drainage to prevent dampness in the walls or interior portion of the building. (IMC 6-110)

Unkept Grounds?

The ground is not kept free from any overgrown vegetation that is an obstruction or problem. (IMC 14-131(c))

There is an accumulation of debris on the sidewalks or other traveled paths. (IMC 14-133)

Trash receptacles are not kept clean and prevented from overflowing. (IMC 14-132)

Poor Electrical Conditions?

Light fixtures, inside and outside, are not in good working order (except cases of burnt out bulbs). (IMC 6-126)

Electrical system is hazardous due to poor maintenance (e.g. electrical wiring is exposed, etc.) (IMC 6-126(a))

Provided major appliances are not in good working order. (IMC 6-123(b) & IMC 6-125(a))

Poor Ventilation Conditions?

Mold is present in the residence. (IMC 6-119)

Bathrooms do not have adequate ventilation, including a non working fan. (IMC 6-116(2))

Residence is not free from any lasting dampness. (IMC 6-119)

Poor Plumbing Conditions?

Toilet(s) is/are not in good working condition. (IMC 6-124(c))

Water heater is not reliable and does not adequately heat water. (IMC 6-125(a) & 6-124(c))

Pipes in the residence are not in good condition. (IMC 6-124(c))

Poor Heating Conditions?

Residence is not able to maintain a comfortable temperature in all habitable rooms. (IMC 6-125(b))

Unsafe Security and Safety Conditions?

Residence does not have at least one present and working smoke detector and/or carbon monoxide alarm. (IMC 6- 130(b))

Exterior doors and windows do not lock securely. (IMC 6-116(4) and 6-117(b))

All exterior glass windowpanes are not free from cracks and/or holes. (IMC 6-116(5))

Infestation Conditions?

Residence is not free from insects or rodents. (IMC 6-120)

Requestor Information

Permit Number(Required)

Payment Date:(Required)

Refund To:

Please fill out the information below for who you want the refund to be sent to.

Name(Required)

Company Name

Mailing Address(Required)

Phone(Required)

Email(Required)

I would like a refund on my permit because:(Required)

Applicant cancelled permit

Duplicate permit - duplicate #

Fee charged in error, explain

Charged for something not used/received, explain:

If your refund request is for a reason not listed above, please explain:

Please Explain:

Signature(Required)

Date(Required)

Month

Day

Year

A $300 fee is required for this permit.

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Project Address(Required)

Project Summary(Required)

Property Owner

Property Owner Name(Required)

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Does the owner of this property own any adjacent property?

Yes

If yes, please list tax map and tax lots:

Property Owner Signature(Required)

If more than one property owner, please check the box on the right and have them sign.

Multiple Owners?(Required)

Yes

Date(Required)

Month

Day

Year

Signature

Applicant

Name(Required)

Business Name (if Applicable)

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Applicant's Interest in Property(Required)

Applicant's Signature(Required)

Date(Required)

Month

Day

Year

Additional Personnel

This section is not required unless you have multiple owners of a property.

Name

Role

Business Name (if Applicable)

Address

Street Address City State ZIP Code

Phone

Project Details

Tax Map(Required)

Tax Lot(s)(Required)

Frontage Street or Address(Required)

Nearest Cross Street(Required)

Comprehensive Plan Designation(Required)

Zoning Designation(Required)

Site Size(Required)

Site Dimensions(Required)

Pre-Application Submittals

Pre-Application Form (Completed, Signed)

The primary contact person responsible for the application must be identified on the form.

Application Fees

A $300 fee, payable to the City of Independence.

Project Narrative

A narrative statement that describes the project, the improvements proposed, and the specific issues or questions that the applicant would like the City to address in the Pre-Application Conference.

Site Plan - A preliminary site plan to scale that shows:

Basic information to orient the project including a north arrow; the scale of the map/plan; abutting streets and alleys, including street names; property lines of the subject site; and the length of each line

Existing and proposed driveway locations. Please label whether they are gravel or paved.

Existing and proposed structures on the site and the distance between the buildings and property lines.

Existing and proposed uses and the square footage of all buildings (if known

Existing and proposed building entries for pedestrians and vehicles.

Existing and proposed parking areas

Optional Information – The following optional information may also be included:

The location of any private wells, septic tanks and drain fields.

The location of any existing public or private recorded easements.

The location of private service laterals (both sewer and water) that are on the site

The location of driveways on abutting properties.

The street elevations of the proposed buildings.

Upload Files and Sign

Upload Files

Drop files here or

Max. file size: 50 MB.

Signature(Required)

Date(Required)

Month

Day

Year

A $60 notice fee is required for this permit and other associated fees.

Please complete the Agreement for Payment of Land Use Application Fees(PDF) and email the completed form to fevander@ci.independence.or.us.

Multiple signatures are required; a link to collect additional signatures will be provided after submission.

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Form Type

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Application Status

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Application Number

General Information

Project Address(Required)

Nearest Cross Street

Tax Map

Tax Lot(s)

Site Size

Site Dimensions

Project Summary(Required)

Applicant

Name(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Applicant's Interest in Property(Required)

Are you the property owner?(Required)

Yes

Property Owner

Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Type I Action - Application Type

*All land use application fees are a base fee amount to be paid to the City. An Agreement for Payment of Land Use Application Fees in the form attached hereto, must be executed by the property owner and submitted to the City with the application Base Fee, as a component of the City’s required application fees. The Agreement shall be recorded against the subject property and run with the land. If the City’s costs for processing an application exceed the Base Fee, the full cost due and payable will be the City’s actual cost, including but not limited to hourly rates for planning, public works, engineering, City administration, legal, wetland and other consultants.

(Should be completed prior to submittal of application)

Land Use Pre-Application (Should be completed prior to submittal of application) - $300

Land Use Actions *

Administrative Variance - $500*

Lot Line Adjustment - $250/lot*

Site Design Review - $2,500

Other Actions

Floodplain Permit - $200

Multiple Dog Permit (Res.) - $30

Dog Kennel (Commercial) - $125

Type II Action - Application Type

(Should be completed prior to submittal of application)

Land Use Pre-Application (Should be completed prior to submittal of application) - $300

Land Use Actions *

Variance - $1,000

Conditional Use - $2,000*

Major Partition - $1,500 + $150/lot*

Subdivision - Tentative Application Fee - $2,500 + $150/lot*

Subdivision - Inspection Fee per IDC 90.60.075(L)(1) - 4% of approved, stamped, engineer's cost estimate

Manufactured Home Dwelling Park - $1,500 + $150/dwelling unit*

Planned Unit Development - $1,500 + $150/dwelling unit*

Total Application Fees

Required Submittals

Please check off what items you have uploaded.

Details necessary for the proposal as specified in the Independence Development Code.

Plot plan of subject property - show scale, north arrow, location of all existing and proposed structures, road access to property, names of owners of each property, etc. Plot plans can be submitted on tax assessor's maps, which can be obtained from the Assessor's office in the Polk County Courthouse, Dallas, OR.

Legal description of the property as it appears on the deed (metes and bounds). This can be obtained at the Polk County Clerk's office in the Courthouse.

A certified list of names and addresses of each owner of all properties within 250' of the subject property. Two sets of mailing labels for each property owner must also be provided. For an additional $25, the city will provide the list and labels.

Agreement for Payment of Land Use Application Fees (notarized).

Would you like the city to supply the list and labels for an additional $25?

Yes - please include $25 to the total due with your application.

Submittal File Upload

Drop files here or

Max. file size: 50 MB.

THE PROPERTY OWNER(S) / APPLICANT(S) SHALL CERTIFY THAT:

The request does not violate any deed restrictions that may be attached to or imposed upon the subject property.
If the application is granted, the Applicant will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval.
All the above statements and the statements in the plot plan, attachments, and exhibits transmitted herewith are true. The applicant(s) acknowledge that any permit issued on this application may be revoked if it is found that any such statements are false.

Applicants Signature(Required)

Date(Required)

Month

Day

Year

A fee is required for this permit. Initial Application: $25 Annual Renewal: $15

*Exempt Businesses (home based, non profit or charitable, educational organizations): No Fee

All Businesses operating within the City, unless specifically exempt, are required to register their business(es) per ordinance Sec 8-1: Business Registration.

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General Business Registration

THIS FORM MUST BE COMPLETED FORM MUST BE SIGNED. BUSINESS NAME, ADDRESS, PHONE AND TYPE OF BUSINESS WILL BECOME PUBLIC RECORD.

Please Choose One:(Required)

New Business

Change of Ownership

Change of Location

Change of Name

Other

Other - Please Specify

Business Information

Business Name(Required)

Number of Employees(Required)

Business Physical Address(Required)

Street Address City State ZIP Code

Mailing Address - If different from physical address

Street Address City State ZIP Code

Business Hours(Required)

Business Phone(Required)

Type of Business Information

Type of Business:(Required)

Retail

Service

Resturant

Convenience Store

Gym

Lawn Maintenance

Home Based*

Non Profit or Charitable*

Educational Organizations*

Other

*Exempt Businesses. Please fill out the form - No Fee.

Other - Please Specify

Description of Business(Required)

May we share the above information with the Monmouth Independence Chamber of Commerce?

Owner/ Operator Information

Owner/Operator Name and Title(Required)

Please Choose One:(Required)

On-Site

Off-Site

Owner/Operator Email(Required)

Owner/Operator Phone(Required)

County/State/Federal License/Certification (if applicable) Type and #:

The following Confidential Emergency Contact Information will be used only by Emergency Services Personnel

Emergency Contact #1(Required)

Phone(Required)

Emergency Contact #2

Phone

Signature

I hereby certify that the information contained herein is true to the best of my knowledge. I agree to abide by the Code of Ordinances of the City of Independence and to correct any hazards or violations that may pertain to the above business.

Signature of Owner/Operator(Required)

Date(Required)

Month

Day

Year

Application Fee

Please contact the City of Independence office to make a payment, 503-838-1212, stop by city hall during office hours: 555 South Main Street, Independence OR. 97351, or mail a check to Attn: Business Registration, 555 South Main Street, P.O. Box 7, Independence OR 97351.

Application Fee

Initial Application Fee

Annual Renewal Fee

*Exempt Businesses. Please fill out the form - No Fee.

Pay Via

Total

A new application fee of $100 is required for this permit.

This must be submitted in addition to the application provided by the State.

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Business Name(Required)

Former Business Name (if applicable)

Business Address(Required)

Street Address City State ZIP Code

Questionnaire

This questionnaire should be completed during the interview of liquor license applicants AFTER RECEIPT OF THE OLCC LICENSE APPLICATION. The information gathered here will serve as a basis for conducting a background investigation on the applicant.

1. List all names, addresses, phone numbers, DOB's, SSN's, ODL's, and any previous names used by ALL persons who have a financial interest in the above listed business.(Required)

2. Provide the current and previous 2 jobs of all persons listed in question number 1 above.(Required)

Current Employer

Job Title

Previous Employer #1

Previous Employer #2

3. List all persons residing in the household of those persons listed in question number 1 above (excluding minor children).(Required)

Name

Relationship

Age (or DOB)

4. What is being used as funding source to purchase the business and get it started? (list who and how much).(Required)

Who

How Much

5. Have any persons listed above ever had any debt turned over to a collection agency?(Required)

Yes

6. Has any person listed above ever been sued?(Required)

Yes

7. Has any person listed in number 1 above been involved now, or have you ever been engaged in any business as an owner, partner, or corporate member?(Required)

Yes

8. Has any person listed in number 1 above ever filed bankruptcy?(Required)

Yes

9. Has any person listed in number 1 above ever had any property repossessed?(Required)

Yes

10. Have any of you ever had your wages garnished or a wage assessment placed against you?(Required)

Yes

11. Have any of you ever been dismissed from a job or forced to resign? If yes, explain.(Required)

Yes

12. Have any of you ever been rejected for a similar business purchase?(Required)

Yes

Please Explain

13. List any experience each of you have in owning, managing, or working in a liquor outlet.(Required)

Please briefly describe any experience owning, managing, or working in a liquor-related business (business name, role, years).

14. Has any person listed in number 1 above ever been arrested, charged, accused, or convicted of any crime (if yes, list date, agency, charge, & disposition).(Required)

Yes

15. Has any member of the immediate family of those persons listed in number 1 above ever been convicted of a crime? If yes, explain.(Required)

Yes

Please Explain

16. What plans do you have for the business in the following areas?

A. Type of alcohol sold (check all that apply)(Required)

Beer

Wine

Distilled Spirits (Liquor)

Cocktails / Mixed Drinks

Cider

Hard Seltzer

Non-alcoholic Beer or Wine

Other (please specify)

Check all that apply:(Required)

On-premises consumption

Off-premises sales (bottles/cans to go)

Other - Please Specify

B. Food service offered (check all that apply)(Required)

Full-service meals

Limited menu / light food

Appetizers / small plates

Prepared food (made on site)

Pre-packaged food only

Food truck on site

Catering services

No food service

Other (please specify)

C. Building plans(Required)

As-is

Remodel

Other - Please Specify

D. Type of client/patrons expected or targeted for (check all that apply)(Required)

General public

Adults (21+)

Families

Tourists / visitors

Local residents

Evening / nightlife patrons

Event-based customers (private events, rentals, etc.)

Take-out / off-site customers

Delivery customers

Other (please specify)

Other - Please Specify

E. Any special activities or plans to draw in customers(Required)

Live music

Karaoke

Dancing

Televised sports / watch parties

Trivia nights

Game nights (board games, video games, etc.)

Themed events or promotions

Private events or rentals

No special activities planned

Other (please specify)

Other - Please Specify

G. Any plans for security.(Required)

H. What is going to be house policy for persons or employees using or possessing drugs?(Required)

Applicant Signature

A $100 fee will be charged for all NEW applications submitted.

Signature(Required)

Date(Required)

Month

Day

Year

A fee is required for this permit.

Marijuana Retailers/Dispensaries: New: $500 Annual Renewal: $300

Marijuana Wholesalers/Manufacturers/Processors: Actual processing costs/$1,000 deposit Annual Renewal: $1,000

Please see ordinance for more information

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Business Information

In addition to any state registration or license, Independence Municipal Code provides that marijuana businesses must also obtain a local license.

Name of Business(Required)

Business Address(Required)

Street Address City State ZIP Code

This Business is Registered with Oregon Health Authority as::

A Medical Marijuana Dispensary

A Medical Marijuana Processing Site

This Business is Licensed with the Oregon Liquor Control Commission as:

A Recreational Marijuana Producer

A Recreational Marijuana Processor

A Recreational Marijuana Wholesaler

A Recreational Marijuana Retailer

Attach proof of OHA registration or OLCC license to this application(Required)

Drop files here or

Max. file size: 50 MB.

Fees

Marijuana Retailers & Dispensaries

Total

Required Information to be Uploaded

Please check the box's to let us know you included the required information.

Section A - The name and address of:(Required)

1. The applicant, including all principals (Note: a principal is a natural person who is a member, partner, or corporate officer, and all stockholders holding more than 10 percent of the voting stock, of any entity);

2. Any person that has an ownership interest in the marijuana business, including all principals;

3. Any person that has loaned or given money, real property or personal property for use by the marijuana business (financial interest) within the preceding 12 months, including all principals;

4. Any person that owns the real property to be used by the marijuana business and any person who manages that property on behalf of the real property owner(s);

5. The natural person that has the responsibility for day-to-day operation or management of the marijuana business; and

Section B:(Required)

For each natural person, including all principals, described in Section A, a copy of the front and back of a valid driver's license or identification card issued by the State of Oregon or the state in which the person resides, or the person's passport;

Section C:(Required)

For each principal of a recreational marijuana business, a copy of the person’s state-issued marijuana worker permit.

Section D:(Required)

Contact information for the medical marijuana business and any person described in Section A.

Section E:(Required)

The name, telephone number, and postal and e-mail addresses of the natural person to receive on behalf of the marijuana business, all correspondence about the license.

Section F:(Required)

A detailed description of the type, nature and extent of the marijuana business including, but not limited to, a description of the products to be provided by the marijuana business and the process by which such products will be manufactured;

Section G:(Required)

If the marijuana business is a medical marijuana dispensary or recreational marijuana retailer, the proposed days and hours of operation of the medical marijuana dispensary or the recreational marijuana retailer;

Section H:(Required)

A dimensioned floor plan, drawn to scale, of the entire space in which the marijuana business is to be located. The floor plan shall indicate the location, nature and extent of the existing and proposed improvements and shall include the following minimum information:

Labeling the principal uses of the floor area of a medical marijuana dispensary or recreational marijuana retailer including, but not limited to, entrance areas, office areas, retail areas, display cases, private consulting areas, and areas where marijuana will be packaged, distributed, stored and/or disposed;

Labeling the principal uses of the floor area of the recreational marijuana producer including, but not limited to, entrance areas, office areas, growing and drying areas, and areas where marijuana will be packaged, stored and/or disposed;

Labeling the principal uses of the floor area of the medical marijuana processor or recreational marijuana processor including, but not limited to, entrance areas, office areas, processing and manufacturing areas, areas where marijuana will be packaged, stored and/or disposed, and areas where flammable materials will be used, stored, or disposed;

For all marijuana businesses, the location and widths of all entrances and exits, exterior lighting and light fixture information, and the general layout of circulation paths, and aisle width in compliance with the applicable building codes adopted by the City of Independence and any other applicable laws*;

Section I**:(Required)

A plan, prepared by a mechanical engineer licensed in the State of Oregon, for controlling and mitigating odor generated by the marijuana business. The plan shall describe in detail the odor control and mitigation systems, which may include but are not limited to ventilation systems and filtration systems, as well as any other best practices that will be used to prevent the odor of marijuana from traveling off the premises. For a recreational marijuana producer, such plan shall also include all ventilation systems used to control the environment for the plants and the plan must describe how such systems operate with the odor-control systems;

Section J:(Required)

A plan for ensuring that any heat and glare created by the marijuana business will not be discernible at or beyond the property line;

Section K:(Required)

A plan showing that exterior lighting will be directed away from and shall not reflect on adjacent properties;

Section L:(Required)

Evidence that the applicant has received all necessary land use approvals and that the location of the marijuana business complies with the requirements of the Independence Zoning Ordinance.

Attachments:(Required)

All written submissions and copies of documents as required in Sections A – L.

Under penalty of perjury, I state that the information contained in this application is current and accurate. *Questions can be directed to the city’s Building Official at 503-838-1212. **Medical Marijuana Dispensaries and Recreational Marijuana Retailers are exempt from this requirement

Signature(Required)

Date(Required)

Month

Day

Year

A $35 fee is required for this permit.

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Business Details

Business Name(Required)

Proposed Address(Required)

Applicant

Name(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Business Contact at Mobile Vending Site (If not applicant)

Name

Phone

Property Owner (If not applicant)

Name

Phone

Signature

Required Submittals

Please click the check box when you have included a submittal with this application.

1. A site plan that shows the following information:

The proposed location of the mobile vendor, and the distance to nearby sidewalks, driveways or structures.

The location of the hard-surface area where a mobile vending device will be located.

The location of any power service to the unit.

The location of proposed garbage receptacles, chairs or other temporary furniture.

The location of any utilities that will serve the unit

A traffic plan, showing the in/out flow of cars; and the parking for customers and employees.

2. A project narrative that includes:

The products being sold.

The means used to conduct the business including, but not limited to, a photo and description of any mobile container or device to be used for the transport or display of merchandise. Additionally, please note if the business will move locations as part of its daily operation.

The proposed hours of operation for the use

An explanation of how employees will use the restroom during the hours of operation.

A disposal plan for wastewater and gray water

3. A valid copy of all necessary permits required by state or local health authorities.

4. Written consent from the property owners where the use will be located, if not the applicant.

Mobile vending devices may operate on city-owned property provided the licensee is granted a site-specific permit, which shall be displayed prominently on-site

5. If the mobile vendor will be located on City property or right of way:

A signed statement that the permittee shall hold harmless the city, its officers and employees, and shall indemnify the city, its officers and employees for any claims for damage to property of injury to persons occasioned by any activity carried on under the terms of the permit.

Public liability, food products liability and property damage insurance to protect the permittee and the city from all claims for damage to property or bodily injury, including death, which may arise from operations under or in connection with the permit.

Required Submittal Upload

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Signature

I certify that the information submitted is true, and I have read the standards of this application.

Signature(Required)

Date(Required)

Month

Day

Year

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Restaurant Details

Name(Required)

Address(Required)

Planned Operation Details

Operation Dates - From:(Required)

Month

Day

Year

Operation Dates - To:(Required)

Month

Day

Year

Daily Hours - From(Required)

Daily Hours - To:(Required)

Applicant

Name(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Property Owner (If not applicant)

Name

Phone

Signature

Required Submittals

Please submit all required materials with your application and mark it off the list so we know it was uploaded.

1. Site plan that shows the following information:

The dimensions of the proposed eating area and distances to applicable streets, curbs and permanent landscaping.

American Disabilities Act clearances on sidewalks (5 feet of passable sidewalk must be maintained).

The location of tables, chairs and waste receptacles.

2. If alcohol is to be served:

A copy of your current OLCC license.

A certificate of liquor liability coverage naming the City as an additional insured

A statement of how the service of alcohol will be managed.

3. Insurance:

A Certificate of Insurance (public liability, food products liability and property damage insurance) and an endorsement naming the City as an additional insured. The insurance shall be in an amount not less than $500,000 to protect the permittee and the city from all claims for damage to property or bodily injury, including death, which may arise from operations under or in connection with the permit.

Submittal File Upload

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Signature

I certify that the information submitted is true, and I have read the standards of this application. I shall hold the City of Independence, its officers, agents and employees free and harmless from any claims for damages to persons or property including legal fees and costs of defending any actions or suits thereon, including appeals therefrom, which may result from granting this permit.

Signature(Required)

Date(Required)

Month

Day

Year

A fee is required for this permit. Individual Solicitor/Peddler $25 Peddlers Crew License $50 (+ $5 per each solicitor/peddler)

Please see ordinances for more information

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Solicitor/Peddler: Please choose one:(Required)

Crew*

Individual

Other

Other - please explain:

Upon submitting this application to the City Recorder, a police background investigation may be conducted. All pages/fields must be completed. This form must be completed in legible handwriting or typed. Illegible applications may be rejected. Application MUST be signed.

Business Information

Business Name(Required)

Business Address(Required)

Street Address City State ZIP Code

Name, Date of Birth, Address, Phone of all Partners or Corporate Officers:(Required)

Name

DOB

Address

Phone #

Add as many as you need with the + toggle on the right.

Products Being Sold: (list all products and type of products being sold):(Required)

Vehicles Used (if appliable)

Year

Make

Model

Lic. No.

Add as many as you need with the + toggle on the right.

Insurance Company(Required)

Agent(Required)

Agent Phone Number(Required)

Policy Number(Required)

Effective Date(Required)

Month

Day

Year

Expiration Date(Required)

Month

Day

Year

For a Crew License application, please complete the following pages for each individual that will be performing the door-to-door solicitation.

Personal History(Required)

First Name

Middle

Last

Add as many as you need with the + toggle on the right.

Present Address(Required)

Address

City

State

Zip Code

Add as many as you need with the + toggle on the right.

Present Personal Information(Required)

Phone

Social Security No.

Date of Birth

Place of Birth

Add as many as you need with the + toggle on the right.

Drivers License Number and State(Required)

Expiration Date(Required)

Month

Day

Year

Have you ever had suspended or revoked driver's license?(Required)

Yes

If yes, state reason, date, and court

Other Names

If marries (maiden)

Nicknames/Surnames

During what period and under what circumstances were these names used?

Have you ever legally changed your name? If so, please provide date, place, and court:

Yes

Please provide date, place, and court

Previous Addresses

Past Addresses - past 5 years

Address

City

State

Zip Code

Add as many as you need with the + toggle on the right.

Physical Description

Gender(Required)

Male

Female

Non-binary

Weight(Required)

Height(Required)

Hair Color(Required)

Light Blonde

Dark Blonde

Light Brown

Dark Brown

Auburn/Red

Black

Gray

Salt & Pepper

Other

Other - Please Specify

Scars/Marks - Please Describe - Put none if you do not have any(Required)

Other Information

City ordinance requires that all peddler license applicants list all criminal offenses other than a Class B, C, or D traffic infraction.

Have you ever been convicted of a criminal offense, except as described above?(Required)

Yes

If yes, state reason, date, and court

Please list 3 persons residing within the state of Oregon who can give an informed account of the business and moral character of the applicant.(Required)

Name

Address

Phone Number

Add as many as you need with the + toggle on the right

I, the undersigned hereby give my consent to the City of Independence Police Department to conduct a background investigation for the purpose of determining my qualifications to be granted a permit. I do further authorize the release to the City of Independence and Independence Police Department all information pertaining to, but not limited to my driving record, police record, or prior employment record. I do certify that all statements made here are true with the understanding that omissions of fact or misstatements on my part shall be cause for forfeiture of eligibility for a permit.

Signature(Required)

Date(Required)

Month

Day

Year

A fee is required for this permit. New Business: $100 Renewal $35

Please see ordinance for more information

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Application Fee(Required)

New Business - $100.00

Renewal - $35.00

Upon submitting this application to the City Recorder, a police background investigation will be conducted. All pages/fields must be completed. This form must be completed in legible handwriting or typed. Illegible applications may be rejected. This application and a separate Taxicab Driver application for each driver MUST be signed.

Business Information

Business Name(Required)

Business Address(Required)

Street Address City State ZIP Code

Name, Date of Birth, Address, Phone of all Partners or Corporate Officers:(Required)

Name

DOB

Address

Phone #

Add as many as you need with the + toggle on the right.

Vehicles Used (if appliable)

Year

Make

Model

Lic. No.

Add as many as you need with the + toggle on the right.

Insurance Requirements

Insurance Company(Required)

Agent(Required)

Agent Phone Number(Required)

Policy Number(Required)

Effective Date(Required)

Month

Day

Year

Expiration Date(Required)

Month

Day

Year

1.For death or injury to any one person in any one accident, not less than $100,000;

2.For death or injury to two or more persons in any one accident, not less than $300,00;

3.For damage to or destruction of property of others resulting from any one accident, not less than $50,000.

File

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Max. file size: 50 MB.

Personal History(Required)

First Name

Middle

Last

Add as many as you need with the + toggle on the right.

Present Address(Required)

Address

City

State

Zip Code

Add as many as you need with the + toggle on the right.

Present Personal Information(Required)

Phone

Social Security No.

Date of Birth

Place of Birth

Add as many as you need with the + toggle on the right.

Drivers License Number and State(Required)

Expiration Date(Required)

Month

Day

Year

Have you ever had suspended or revoked driver's license?(Required)

Yes

If yes, state reason, date, and court

Other Names

If marries (maiden)

Nicknames/Surnames

During what period and under what circumstances were these names used?

Have you ever legally changed your name? If so, please provide date, place, and court:

Yes

Please provide date, place, and court

Previous Addresses

Past Addresses - past 5 years

Address

City

State

Zip Code

Add as many as you need with the + toggle on the right.

Physical Description

Gender(Required)

Male

Female

Non-binary

Weight(Required)

Height(Required)

Hair Color(Required)

Light Blonde

Dark Blonde

Light Brown

Dark Brown

Auburn/Red

Black

Gray

Salt & Pepper

Other

Other - Please Specify

Scars/Marks - Please Describe - Put none if you do not have any(Required)

Other Information

Have you ever been convicted of any crime, misdemeanor or violation of municipal ordinance (Other than minor traffic and parking offenses)?(Required)

Yes

If yes, state reason, date, and court

Please list 3 persons residing within the state of Oregon who can give an informed account of the business and moral character of the applicant.(Required)

Name

Address

Phone Number

Add as many as you need with the + toggle on the right

Signature(Required)

Date(Required)

Month

Day

Year

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Company

This field is for validation purposes and should be left unchanged.

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Form Type

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Approval Status

Service Discontinued Date(Required)

MM slash DD slash YYYY

(Minimum 5 Day Notice Required)

Applicant Name(Required)

First Last

Service Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Were You a Renter or Owner

New or Forwarding Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Check Refund Made Out to (Name)(Required)

First Last

Email(Required)

Phone(Required)

Refund Check ACH/Direct Deposit(Required)

I am interested in setting up direct deposit/ ACH for my deposit refund. (If box is checked "YES" Accounts Payable will contact you to set up this service).

Yes

Acknoledgement(Required)

By checking this box, I understand that by disconnecting my service as outlined in the above document, I may sustain additional charges for reconnection of service.

Date(Required)

MM slash DD slash YYYY

Agrees to all Terms & Conditions(Required)

Sec. 34-127. - Water service billing.
(a)All billings for water service shall be made monthly on the basis of the amount of water used during the previous monthly period, and the monthly base rate minimum (See subsection (c) of this section below). Amounts billed will not be reduced for loss of water due to waste caused by leakage of equipment of the customer, except as provided in section 34-409(a).
(b)If, for any reason, it is impossible or impractical to read the meter, consumption may be estimated, based on the previous history of use, until the meter can be read.
(c)The city shall commence charging the water base rate for all occupied property either 60 days after the water service becomes available or the day that connection is made to the public water system, whichever occurs first. The water base rate for all unoccupied property shall begin within 30 days after the property is ready for occupancy or on the first day of occupancy, whichever occurs first. All unoccupied property which is ready for occupancy at the time the water service becomes available shall be treated as occupied property. Once the water base rate has commenced, no credit shall be given for vacancy, unless a property owner gives written notice to disconnect from the water system per section 34.405.2.
(d)Water billing and collection procedures shall be performed as provided in article VI of this chapter.
(Code 2006, § 13.5.28; Ord. No. 1495, § 1(13.5.29), 1-25-2011; Ord. No. 1528, § 1, 3-11-2014)

Sec. 34-312. - Sewer User Charges.
(a)User charges shall be levied on all users of the public treatment works. The user charges shall, at a minimum, cover the cost of operation and maintenance, replacement, system planning and construction and other administrative costs of such treatment works. The user charge system shall distribute these costs in proportion to each user's contribution to the wastewater loading of the treatment works. The minimum charge shall be that cost equivalent to treatment of the wastewater from an average residential dwelling unit.
(b)There shall be assigned to each user an appropriate number of ERUs and this number shall represent the ratio of the wastewater produced by the user to the wastewater produced by the average residential dwelling unit; provided, however, that each residential user discharging only domestic waste into the sewer system shall be levied a user charge calculated on the basis of the use of one ERU per dwelling unit.
(c)The user charge shall be calculated by multiplying the total number of ERUs for each user by a constant cost factor. This cost factor shall be established from time to time by resolution of the City Council as provided in section 34-313
(d)Should any user believe that the user has been assigned an incorrect number of ERUs, that user may apply for review of the user charge as provided in section 34-316
(e)If it has been determined by the city that a user is assigned an incorrect number of ERUs, the city shall reassign a more appropriate number of ERUs to that user and shall notify that user of such reassignment.
(f)Records of all rates and the number of ERUs assigned to each user, as well as the wastewater characteristics forming the basis of the ERU, shall be kept on file with the City Recorder and shall be open for public inspection.
(g)The city shall commence charging the sewer user charge for all occupied property either 60 days after the sewer service becomes available or the day that connection is made to the public sewer system, whichever occurs first. The sewer user charge for all unoccupied property shall begin within 30 days after the property is ready for occupancy or on the first day of occupancy, whichever occurs first. All unoccupied property which is ready for occupancy at the time the sewer service becomes available shall be treated as occupied property. Once the sewer user charge has commenced, no credit shall be given for vacancy unless a property owner gives written notice to disconnect from the water system per section 34.405.2.
(Prior Code, § 71.220; Code 2006, § 13.12.4; Ord. No. 1495, § 2(13.12.4), 1-25-2011; Ord. No. 1528, § 2, 3-11-2014)

By checking this box, I have reviewed and understand the above Municipal Codes. Once the water and sewer user charge has commenced, no credit shall be given for vacancy unless a property owner gives written notice to disconnect from the water system per section 34.405.2.

Date(Required)

MM slash DD slash YYYY

CAPTCHA

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Approval Status

The undersigned hereby applies for Sewer and/or Water Services and agrees to the following terms and conditions:

The applicant will abide by the Independence City Code and all rules and regulations adopted for the utility system (IMC Chapter 34 – Utilities).
The applicant will provide the information below, per IMC Section 34-401 – Application for Utility Service.

For the most current Independence City Codes, please visit the City’s Code of Ordinances and search the IMC sections and chapters listed above, or inquire at City Hall.

Service Address(Required)

Date(Required)

Month

Day

Year

Owner(s) Name(Required)

Business Name (if a business)

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Emergency Contact (Name & Phone #)(Required)

I am the owner and occupant of the property for which water/sewer service is being requested. I guarantee that if I fail to make payments in accordance with the rules, regulations and ordinances of the City of Independence, I will pay such arrearages and be liable for those charges, including any penalties and interest accrued. I further agree that City may lien my property, identified above, in the amount of any unpaid delinquent utility bills.

Signature of Property Owner(Required)

Date(Required)

Month

Day

Year

Signature of Additional Property Owner - If applicable

Date

Month

Day

Year

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Approval Status

The undersigned hereby applies for Sewer and/or Water Services and agrees to the following terms and conditions:

The applicant will abide by the Independence City Code and all rules and regulations adopted for the utility system (IMC Chapter 34 – Utilities).
The applicant will provide the information below, per IMC Section 34-401 – Application for Utility Service.

For the most current Independence City Codes, please visit the City’s Code of Ordinances and search the IMC sections and chapters listed above, or inquire at City Hall.

Service Address(Required)

Date(Required)

Month

Day

Year

Owner(s) Name(Required)

Business Name (if a business)

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Emergency Contact (Name & Phone #)(Required)

Property Owner or Management Company will be contacted to verify applicant information

Signature of Property Owner(Required)

Date(Required)

Month

Day

Year

Signature of Additional Property Owner - If applicable

Date

Month

Day

Year

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The undersigned hereby applies for Sewer and/or Water Services and agrees to comply with the following terms and conditions:

The applicant will abide by the Independence City Code and all rules and regulations adopted for the utility system (IMC Chapter 34 – Utilities).
The applicant will provide the information below, per IMC Section 34-401 – Application for Utility Service.
The applicant acknowledges that this property is a rental property and affirms that renters have permission to apply for utility service.

For the most current Independence City Codes, please visit the City’s Code of Ordinances and search the IMC sections and chapters listed above, or inquire at City Hall.

Service Address(Required)

Date(Required)

Month

Day

Year

Property Owner Information

Owner(s) Name(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Check box if this applies to your property

I agree that the following Property Management company has my permission to handle business pertaining to the water/sewer utility billing with the City of Independence regarding the property, and that Property Management will receive notices in lieu of the owner. This consent will remain in effect until the City is notified by the owner, in writing

Management Company Information (if applicable)

Management Company Name

Contact Person Name

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

I am the owner/management co. of the property for which water/sewer service is being requested. I guarantee that if I/the tenant fail to make payments in accordance with the rules, regulations, and ordinances of the City of Independence, I will pay such arrearages and be liable for those charges, including any penalties and interest accrued. I further agree that City may lien my property, identified above, in the amount of any unpaid delinquent utility bills.

Signature of Property Owner/Management Company(Required)

Date(Required)

Month

Day

Year

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Informal Complaint

Formal Complaint

Complainant Information

Name(Required)

Address(Required)

Phone #(Required)

Date of Birth(Required)

Month

Day

Year

ID/Driver License #(Required)

Information About Complaint

Police Officer(s) Involved

Location of Occurrence(Required)

Date(Required)

Month

Day

Year

Time Occurred

Hours

Minutes

Was there witnesses?(Required)

Yes

Please list witnesses

Name

Address

Phone #

Please add additional lines with the + toggle on the right if more than one witness.

Detailed Statement

Include as many details of what occurred as possible. Please be specific. Please read below before writing statement.

Please Read(Required)

I. COMPLAINTS AGAINST POLICY OR PROCEDURES: Some complaints are
about certain policy or procedure, rather than against an individual police officer. For example, you may object to the use of radar, or the lack of adequate patrol in a certain area. Many of these complaints can be handled by talking with a police officer. If you are not satisfied with the explanation, ask to speak to a patrol supervisor. A supervisor will assist you in settling the matter or refer you to someone else.

II. COMPLAINTS ALLEGING MISCONDUCT BY AN INDEPENDENCE POLICE OFFICER: If your complaint is against a particular Police Officer for doing something that may constitute a misconduct, ask to speak directly to the
shift supervisor. Your cooperation in reporting the complaint directly to the supervisor will enable us to expedite processing your complaint up the chain of command. All complaints will be brought to the attention of the Chief of Police.
The shift supervisor will determine if the alleged act does not constitute misconduct and will explain this to you. In some cases, your complaint may have to be decided by a court and not by the police department. For example, a dispute over the speed on a traffic citation would be a function for the court to decide. It
would be improper for the police department to usurp the court’s functions. On the other hand, if the police officer did something that would be misconduct, your complaint will be processed. There are two ways that you may wan to elect to
process your complaint, informally or formally.

III. INFORMAL COMPLAINTS: Occasionally, an individual will want to report an act of misconduct, but will merely want it brought to a supervisor’s attention so that the police officer can be counseled if he/she is wrong. The individual will not want to make a formal complaint. If you want your complaint handled in this manner, merely explain the situation to a supervisor. Unless the allegation is so
serious that formal investigation is required, you will not have to write out a formal statement, and no formal discipline will be taken against the police officer. The supervisor will merely talk to him/her and counsel him/her if he/she is
wrong.

IV. FORMAL COMPLAINTS: If you file a formal complaint against a police officer, it will be thoroughly investigated. If the complaint is sustained, administrative disciplinary action may be taken. However, your cooperation is needed in this type of complaint. This will require that you complete the reverse side of this
form and be reasonably available to speak to an investigator. Without your cooperation, the police department will not be able to successfully process your complaint. If you file a formal complaint and cooperate in the investigation, you will be notified by letter of the results of the investigation.

V. FALSE AND MALICIOUS COMPLAINTS: The Independence Police Department encourages individuals to report any acts that they consider to be wrong so we can correct any mistakes in our policies or correct any mistakes made by police officers. No legitimate complaint will be discouraged, but you should be aware that all police officers are entitled to legal counsel in disciplinary proceedings; and any complaint that is found to be false or malicious in nature
may subject the complainant to possible judicial punishment or civil liability.

I agree to the privacy policy.

Detailed Statement(Required)

I have read the reverse side of this form and wish to make a formal complaint. I understand that an investigation will be conducted, and I will fully cooperate with the investigation. I sincerely and truly declare and affirm my knowledge and belief. Further, I declare and affirm that my statement has been made voluntarily without persuasion, coercion, or promise of any kind. I understand that, under the regulations of the police department, the officer against whom this complaint is filed may be entitled to request a hearing before a board of inquiry. By signing and filing this complaint, I hereby agree to appear before a board of inquiry, if one is requested by an officer, and to testify under oath concerning all matters relevant to this complaint.

Complainant Refused to Sign

Yes

Signature or Complainant(Required)

Date(Required)

Month

Day

Year

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Independence Municipal Code 26-256 Permit Required

No person shall organize or participate in a parade which may disrupt or interfere with traffic without obtaining a permit. A permit shall always be required of a procession of people utilizing the public right-of-way and consisting of 15 or more persons or five or more vehicles

Please complete the following application and submit it at least 15 days prior to the intended date of the parade or road closure. If the parade is on a state highway, a separate parade permit may be required by the state.

Name of person responsible for event:(Required)

Address:

Phone:(Required)

Event Information

Reason for Permit(Required)

Parade

Road Closure

Date of Event(Required)

Month

Day

Year

Begin at Time(Required)

Hours

Minutes

AM/PM

Location

End at Time(Required)

Hours

Minutes

AM/PM

Location

Describe the Parade Route or Road Closure Area(Required)

If a Parade - Estimate the number of entries expected

1. Vehivles/Floats

2. Persons on Foot

3. Animals (specify)

Describe the type of parade/event and the purpose(Required)

Please read and agree(Required)

If the Chief of police, upon receipt of this application, determines that the parade can be conducted without endangering public safety and
without seriously inconveniencing the general public, the Chief shall approve the route and issue the permit. You will be notified of this within 5 days of the receipt of this application. If denied by the Chief of Police, the applicant shall have the right to appeal the person’s decision to the City Council (Independence Municipal Code 26-258).

Applicant is responsible for a minimum two-hour rate when Public Works service or equipment is requested.

I have read and agree to the above statement.

Applicant Signature(Required)

Date(Required)

Month

Day

Year

This application includes a $5 upfront fee and may require other associated fees. For additional information, please contact the Independence Police Department at 503-838-1214 or ipd.intake@ci.independence.or.us.

IPD is open Monday - Friday 8:00 am - 5:00 pm. Closed from 11:30 - 12:30 for lunch and closed holidays

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Currently we can only search automated files October 2003 to date. Searches on older files are made only upon specific request. Some records may be exempt from disclosure or may be held by another agency. Submitting a request does not guarantee the release of records.

Requestor Information

Date of Request(Required)

Month

Day

Year

Name(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Email(Required)

Phone(Required)

Preferred Method of Contact(Required)

Mail

Phone

Record Type

$5 upfront fee

Check all that apply:(Required)

Report Request - $1 per page

Address Scan

Name Scan

Policy Request

Please complete the following information

Reason for Request(Required)

Incident/Case Number

Location

Date Range - To

Month

Day

Year

Date Range - From

Month

Day

Year

Person(s) Involved (check all that apply)(Required)

Myself

Another Individual

A business or organization

A specific address or location

A City department

A specific employee or officer

Name(s) and Age(s) (if applicable)

Name

Age

Please add additional lines with the + toggle on the right if more than one person.

Purpose of the Request (optional)

Personal use

Legal matter

Media / journalism

Research

Insurance

Other

Preferred Format for Records

Electronic (email or download)

Paper copies

CD / USB (if available)

Inspection only

Delivery Method

Mail

In-person pickup

Additional Information

Fees

Requests taking more than 10 minutes will be charged an additional fee of $25 per hour. We will call you to advise of an estimated cost and down payment before beginning the process.

Please choose if applicable

Photos (2 photos / page, $1 per page)

Recordings ($20) All recordings will be blurred per ORS 192.345

Public records are writings containing information relating to the conduct of the public’s business. Writings include handwritten, typed, photographed, electronic, or otherwise recorded words, letters, pictures, sounds, symbols, or combinations of these mediums.

There are numerous exceptions to public records laws that allow a public body to refuse disclosure of certain records (see ORS 192.314–192.338, ORS 192.345, and ORS 192.355). Public bodies are not required to explain or answer questions about their public records, nor are they required to create records where none exist.

Public bodies are required to make available for inspection and copying, subject to applicable exemptions, only those records that exist at the time the request is received.

The department may require up to five (5) business days to initially respond to your request. The first contact from the Police Records Office will advise you of the estimated costs involved in fulfilling your request.

Estimated costs must be prepaid before any additional work is performed. No public records request will be processed without prepayment of the estimated cost.

Once prepayment has been received, staff will contact you within ten (10) business days to:

Advise that the requested records are ready for review;
Provide a date when records may be reviewed, picked up, emailed, or mailed; or
Advise that the request is being denied.

If your request is denied, a written explanation of the reason for denial will be provided by the Police Records Office within a reasonable amount of time.

Full payment of all costs incurred is required before public records may be inspected or copies released.

You will be required to pay processing costs even if no records are found or if the records are exempt from disclosure.

Most records available for public inspection are the property of the Independence Police Department. Nothing may be altered, added, or removed from these records, and photographing documents is not permitted.

Allowing inspection or copying of public records does not waive or restrict any copyright, confidentiality, privilege, exemption from disclosure, or other legal rights associated with the records.

Is this request for the purpose of detecting or apprehending persons for the purpose of enforcing Federal Immigration law?(Required)

Yes

I have read and agree to comply with the above conditions.

I further agree to pay the costs of fulfilling this Public Records Request in accordance with the conditions set forth above and the fee schedule adopted by the City Council in effect at the time my request is submitted.

These costs may include, but are not limited to:

Locating records (regardless of whether the requested records are found);
Reviewing records for exempt material;
Supervising the inspection of records;
Copying records;
Certifying records; and
Mailing records.

Requestor Signature(Required)

Date(Required)

Month

Day

Year

Phone ID REQUIRED and applicant must be at least 14 years of age.

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Approval Status

PHOTO ID REQUIRED (copy will be retained). APPLICANTS MUST BE AT LEAST 14 YEARS OF AGE

Name(Required)

First Middle Last

Home Phone

Work Phone

Cell Phone(Required)

Home Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

Month

Day

Year

SSN #

(Optional - used for records check only)

Driver License Number & State(Required)

Purpose of Ride(Required)

Please describe why you are requesting to participate in the ride-along.

Emergency Contact Information

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Date You Want to Ride(Required)

Month

Day

Year

Time Requested

Please leave blank for all day.

Hours

Minutes

AM/PM

Patrol observation rides are a maximum of 5-hour duration. You are limited to 1 ride per calendar year. Please schedule as far in advance (7 DAY MINIMUM) as possible. You will be contacted by telephone to confirm whether or not there is a vacancy for the date and time you have selected. IF SELECTED TO RIDE, YOU ARE BEING REQUESTED TO SHOW UP WEARING CLOTHING DEEMED AS BUSINESS CASUAL.

Ride Rules & Acknowledgements

Consent(Required)

The applicant named above hereby acknowledges and declares that this application is made with the following understandings
and stipulations.

1. The applicant will ride as a passenger in motor vehicles owned by the City of Independence and operated by employees of the Independence Police Department. Such transportation is furnished to the applicant purely gratuitously, as a revocable privilege, so that the applicant may observe the daily, routine operation of the Independence Police Department on patrol.

2. Routine patrol duties may involve the operation of the police vehicles in emergency conditions as authorized emergency
vehicles as permitted by O.R.S. 820.300. Such operation may involve greater than normal speeds, justified disregard of certain traffic control devices and rules of the road, etc. The circumstances requiring emergency operation may include, but are not limited to, pursuit of other vehicles and expeditious transit to suspected crimes in progress. Such circumstances are so varied that an exhaustive list cannot reasonably be compiled. Determination of when to operate a police vehicle as an emergency vehicle is within the sole discretion of the Independence Police Department and its officers.

3. Police work involves, by its very nature, many hazards beyond the power of the police department and its officers to control. At all times while riding as a patrol observer, the applicant agrees, without question or hesitation, to abide by the directions of the Independence Police Department given by its officers, and further recognizes that those directions may
not effectively eliminate risk to the applicant, which risk the applicant assumes.

4. The applicant recognizes that in an emergency, a police officer may not be able to both perform their duty and dismiss the
applicant from their presence, thereby subjecting the applicant to the same risks as are presented to the officer. The applicant recognizes and acknowledges assumption of this risk.

5. The applicant recognizes that criminal charges and/or civil suits arise from many of the situations that confront police officers in their daily work. The applicant agrees to keep confidential all observations and conversations which may merge as a result of their participation in this program. The applicant recognizes the possibility of being civilly liable for any disclosures of this confidentially.

6. The applicant recognizes that during the course of participating in patrol observation, the applicant will become a witness
to traffic offenses and criminal violations. The officer will provide the applicant’s name and address as a witness whenever applicable. The applicant acknowledges that as a witness, there is a potential of being subpoenaed to testify in
court.

7. The applicant recognizes that if medical assistance, including first aid and/or ambulance service, is necessary, the Independence Police Department will arrange for the same, consent for which is hereby given, and agrees to pay any and all costs incurred or accruing in connection therewith.

8. In consideration of the acceptance of this application and granting by the Independence Police Department of the privilege of acting as a patrol observer, the applicant does hereby forever release, discharge and acquit the City of Independence, its officers, agents and employees from any and all claims for death, personal injury and/or damage to property of any nature which may arise from or in connection with their participation hereunder.

9. This ride along may be canceled or terminated at the discretion of the shift supervisor.

10. THE APPLICANT DECLARES TO HAVE CAREFULLY READ AND FULLY UNDERSTAND THE FOREGOING: and, by signature affixed hereto, accepts the same and assents thereto in its entirety.

I agree to the privacy policy.

Are you under 18 years of age?(Required)

Yes

Applicant Signature(Required)

Date(Required)

Month

Day

Year

Parent/Guardian Signature

Parent Name

Parent Signature

Date

Month

Day

Year

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Approval Status

Applicant Information

Date of this request(Required)

Month

Day

Year

Name(Required)

Organization

Phone(Required)

Event Information

Type of engagement(Required)

Other - Please describe

Location of engagement(Required)

Preferred Date(Required)

Month

Day

Year

Preferred Time(Required)

Hours

Minutes

AM/PM

Alternate Date(Required)

Month

Day

Year

Alternate Time(Required)

Hours

Minutes

AM/PM

Topic(s) of Presentation(Required)

Check all that apply

Crime prevention

Personal safety

Neighborhood Watch

Traffic safety

Drug awareness

Scam / fraud prevention

Youth safety

Community policing

Emergency preparedness

Other (please specify)

Other - please specify

Audience Number Expected(Required)

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Application Status

Applicant Information

Name(Required)

First Last

Age(Required)

Adult

High School

Middle School

Address(Required)

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Birth Date(Required)

Month

Day

Year

Driver's License #(Required)

Consent(Required)

* Volunteers must be able to provide their own transportation and may be required to complete and pass a criminal background check.

* Volunteer applications are kept on file for one year, and will be used to fill open positions as they occur.

* If you are interested in serving on a City Board or Commission, please complete a Committee Appointment Application at the top of the Boards and Commission page.

I have read the above statements

Volunteer Information

Volunteer Opportunities(Required)

Check all that apply

Library

Museum

Parks

Police

Other (please specify)

Other - please specify

Days Available(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Time Available(Required)

8–10 am

10 am–12 pm

12–2 pm

2–4 pm

4–6 pm

6–8 pm

All Day

Any relevant or special skills that you want us to know?

Volunteer Signature(Required)

Date(Required)

Month

Day

Year

Signature of Parent/Guardian (if under 18 years of age)

Date

Month

Day

Year

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Approval Status

Date Leaving(Required)

Month

Day

Year

Date Returning(Required)

Month

Day

Year

Name(Required)

Phone #(Required)

Address(Required)

Street Address City State ZIP Code

Emergency Contact(Required)

Name

Phone #

Please add additional lines with the + toggle on the right if more than one contact.

Keys Left With/Name of Key Holder:(Required)

Lights left on?(Required)

Yes

Lights on Timer?(Required)

Yes

Vehicles on Property?(Required)

Yes

Is there an active security system?(Required)

Yes

Vehicle(s) Details

If yes, security system provider

Security system provider phone #

Hazards or Obstacles?(Required)

(e.g., dogs, swimming pool, clotheslines, terrains, other hazards)

Details about our home.

Will anyone be checking the property?(Required)

(mail, pets, plants)

Yes

Will anyone be spending time at the house overnight?(Required)

Yes

If yes, name of person checking property

If yes, name of person spending time on property

Is the house vacant?(Required)

Yes

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Active Status

Applicant Information

Please Choose One:(Required)

Initial Application

Renewal Application

Date of Birth(Required)

Month

Day

Year

Applicant Name(Required)

First Last

Business Name

Property Address(Required)

Street Address City State ZIP Code

Phone #(Required)

Applicant same as owner?(Required)

Yes

Property Owner Information

If different than applicant information

Property Owner Name(Required)

First Last

Mailing Address(Required)

Street Address City State ZIP Code

Phone #(Required)

Secondary Contact Information

Name of Secondary Contact(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Phone #(Required)

Consent(Required)

By affixing my signature to this document I am identifying myself as the responsible party for the property listed above and do hereby
designate each and every police officer employed by the City of Independence as my agent and representative for the purpose of
enforcing ORS 164.245 of the Oregon Revised Statutes.

I further understand and agree that as the responsible party for the property, I will:

• Appear in a court of law for any proceedings related to the enforcement of this TLC.
• Notify any other occupants or tenants of my participation in the TLC program.
• Immediately notify the police department of any changes to property status.

Unless revoked by the City of Independence, this authorization shall continue in force for one year from the first day of the month in which the authorization was granted. (e.g., an application approved on October 15 will expire October 1 of the following year.)

I agree to the above statement.

Applicant Signature(Required)

Date(Required)

Month

Day

Year

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Approval Status

Applicant Information

The City of Independence solicits applications from individuals who have an interest in public service for appointment to periodic vacancies in City Boards, Commissions and Committees. If you have such an interest, please provide the following information:

Name(Required)

First Last

Todays Date(Required)

Month

Day

Year

Mailing Address(Required)

Street Address City State ZIP Code

Phone #(Required)

Email(Required)

Please choose one:(Required)

I AM a resident of the City of Independence Oregon

I am NOT a resident of the City of Independence Oregon

Board/Commissions of Interest

I am interested in appointment to:(Required)

Feel free to indicate interest in more than one. *Attendance at city-funded training is required for appointees to the Planning Commission and Historic Preservation Commission.

Budget Committee

Independence Days Commission

Museum Advisory Board

Planning Commission *

Historic Preservation Commission *

Library Board

Parks & Recreation Board

Traffic Safety Commission

Other: (please specify)

Other: please specify

Experience & Qualifications

Please answer the following questions, attaching additional sheets as needed may be necessary.

1. Experience serving on an elected board:(Required)

2. Experience volunteering with the City of Independence:(Required)

3. Describe your community involvement experience:(Required)

4. Describe your vision for the future of Independence:(Required)

5. If applying for the Budget Committee, please describe your experience with budgeting and public finance:(Required)

6. Describe the time commitment you are able to make to your chosen Committee/Commission/Board:(Required)

7. Your reason(s) for applying for the Committee/Commission/Board:(Required)

Volunteer service on commissions, committees and boards does require effort and time from members. Your interest and participation can help your community and is greatly appreciated. Appointments made to boards, commissions and committees are made by the Mayor, with the confirmation of the City Council.

Signature(Required)

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Applicant Information

Owner Name(Required)

First Last

Residence Address(Required)

Street Address City State ZIP Code

Residence Phone(Required)

Email(Required)

Business Information

Business Name(Required)

Business Address(Required)

Street Address Mailing Address City State ZIP Code

Business Phone(Required)

Name of Operator or Manager(Required)

How long have you owned or operated this business?(Required)

If you own more than one business subject to Transient Room Tax, complete the following:

Name of Business

No. of Rooms

Business Address

How long owned

Please add additional lines with the + toggle on the right if more than one business.

Tax Entity(Required)

Please choose one

Sole Proprietor

Ltd. Liability Co

Partnership

S- Corporation

Corporation

Trust

Estate

Other

Names of Partners or Corporations Officers

Name

Title

Address

Please add additional lines with the + toggle on the right if more than one.

Accounting Year

Begins Date(Required)

Month

Day

Year

End Date(Required)

Month

Day

Year

Please Note: Per Independence Municipal Code Chapter 28, Sec. 28,40-51, a security deposit (not to exceed twice the operator’s estimated average monthly liability or $5,000, whichever is less) for the collection of the tax may be required for the period in which tax returns are filed. This security deposit, if required, may be in the form of cash, bond, or other security deemed proper by the City Recorder.

Signature(Required)

Title(Required)

Date(Required)

Month

Day

Year

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OPERATORS: Complete and remit this form each month to fulfill your Transient Lodging Tax reporting requirement pursuant to IMC Chapter 28, Sec. 28, 40-58. Information provided herein will be kept confidential to the extent allowed by law.

To avoid penalty, this form with proper payment must be received by the City of Independence City Recorder by the 15th day after the end of the month being reported. Remittances are considered delinquent if not paid by the end of the month due.

Checks, drafts, postal notes and money orders in the exact amount of tax due are accepted by the City only as agents of the taxpayer and do not constitute payment until cleared. The City assumes no responsibility for loss in transit.

Changes of address must be filed and reported immediately; likewise if the business is disposed of or suspended, a closing return must be filed immediately with the City of Independence City Recorder and the tax due must be paid. No change of ownership can be recorded until such action is completed.

Remit payments, changes of address etc. to: City of Independence, Finance Director, PO Box 7, Independence, OR 97351. Make checks payable to: "City of Independence";.

Report for Month of:(Required)

Name of Establishment:(Required)

Contact Person:(Required)

Phone:(Required)

Email:

Mark the type of facility:(Required)

Hotel

Motel

Bed & Breakfast

Campground/ RV Park

Educational/ Public/ Non-profit

Monthly Occupancy Levels

a. Number of Units

Number of Units

b. Calendar days in Month

Calendar days in Month

c. Total room nights available

Total room nights available

d. Number of room nights not available for rent (out of service, gratis, etc.)

Number of room nights not available for rent (out of service, gratis, etc.)

e. Net room nights available

Net room nights available (Lines d & c subtracted)

f. Room nights not sold

Room nights not sold

g. Room nights sold

Room nights sold

h. Room nights for occupancies for more than 30 days

Room nights for occupancies for more than 30 days

i. Room nights with rents less than $2 per day

Room nights with rents less than $2 per day

j. Room nights sold to Federal Government Employees on Government business

Room nights sold to Federal Government Employees on Government business

k. Net taxable room nights sold

Net taxable room nights sold

Transient Occupancy Tax Calculation

1. Gross Rent for month

Gross Rent for month

a. Rent for Occupancies of more than 30 consecutive days

b. Rent less than $2 per day

c. Rent for Federal Government Employees on Government business

d. Exclusion of goods or commodities

Rent for Occupancies of more than 30 consecutive days

Rent less than $2 per day

Rent for Federal Government Employees on Government business

Exclusion of goods or commodities

2. Total allowable deductions

Total allowable deductions

3. Taxable Rents

Taxable Rents

4. Total Tax Due: 9%

Total Tax Due: 9%

5. Interest (Add 1% per month if paid after due date)

Penalty (Add 10% of tax due if paid after the end of the month due)

6. Penalty (Add 10% of tax due if paid after the end of the month due)

Interest (Add 1% per month if paid after due date)

Operator collection & remittance expense (optional)(Required)

Yes

Operator allowance total amount

8. Adjustment for prior shortage or overpayment (written claim required)

Adjustment for prior shortage or overpayment (written claim required)

Enter a positive number (+) for an amount owed (red), or a negative number (–) for an overpayment/credit (green). Written claim required for credits.

Please upload your written claim here if applicable.

Max. file size: 50 MB.

9. TOTAL TAX, INTEREST, PENALTY AND ADJUSTMENTS

TOTAL TAX, INTEREST, PENALTY AND ADJUSTMENTS

Remit payments, changes of address etc. to: City of Independence, Finance Director, PO Box 7, Independence, OR 97351.

Make checks payable to: City of Independence.

I declare, under penalty of making a false statement, that to the best of my knowledge and belief the statements herein are correct and true.

TOTAL AMOUNT DUE

TOTAL AMOUNT DUE:

This is the total amount to remit to the City of Independence.

Signature(Required)

Title(Required)

Todays Date(Required)

Month

Day

Year

A $165 fee is required for this permit.

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Form Type

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Approval Status

General Information

Project Address(Required)

Project Description(Required)

The proposal seeks the following action:(Required)

Alteration of Existing Structure

New Construction

Demolition

Other

Property Owner

Name(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Signature(Required)

Date(Required)

Month

Day

Year

Applicant

Name(Required)

Business Name (if Applicable)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Applicant’s Interest in Property

Required Submittals

Please mark what you will be submitting

New Structure

If you seek to construct a new structure, please submit:

Site Plan

Building Elevations

Building Plans

Depictions of neighboring buildings including photos and estimates of the existing building setbacks and heights

Alteration to Structure

If you seek to alter a historic structure, please submit:

Photos that show existing conditions

Plans to show proposed changes

Existing and proposed materials

A narrative that explains the project. The narrative should answer the following questions:

Why is the application proposed?

What historic materials will be impacted?
How has mitigation sequencing (avoidance, minimization and mitigation) been considered?
Please explain your investigation of each step of the mitigation sequencing process listed below:

Priority One - Avoidance of Impact

Please explain the alternatives that you considered to avoid impacts to historic features/materials, and why the total avoidance of the impact is not possible.

Example: If windows are proposed to be replaced for energy efficiency, please explain the alternative means that you considered to promote energy efficiency in the structure, and why those measures alone are not appropriate to promote efficiency.

Priority Two - Minimization of Impact

If an impact cannot be avoided, please explain how you propose to minimize the impact to historic features/materials.

Example: If a window replacement is necessary for bedroom egress, please explain how the impact will be limited to that window.

Priority Three - Mitigation of Impact

If an impact is necessary (following the consideration of the avoidance and minimization of a potential impact), please explain how you plan to mitigate the impact.

This should include a description of the existing materials that will be impacted, and a depiction of the materials that will be used.

Demolition or Relocation of Structure

If you seek to demolish a structure, please submit evidence to demonstrate that at least one of the following criteria is met:

Criterion A. No prudent or feasible alternative to the demolition or relocation of the building exists. Appropriate evidence may include financial estimates for construction costs, structural analyses, etc.

Criterion B. The building or structure is deteriorated beyond repair and cannot be rehabilitated to provide a reasonable economic return compared to other structures in the general area. Appropriate evidence may include structural analyses, development/remodel pro form as, market analyses of comparable real estate, etc.

Criterion C. There is a demonstrated public need for the proposed new use or development that outweighs any public benefit that might be gained by preserving the subject building. Please talk with the City Planner about what evidence might satisfy this criterion.

File Submittal Upload(Required)

Please upload all submittal materials here.

Drop files here or

Max. file size: 50 MB.

Project Details

Please check that you have completed the selected details:(Required)

Complete application

Information sufficient to show the details of the project - Required submittals for the various project types are listed on the back of this sheet.

Written consent from the property owners where the use will be located, if not the applicant

Payment for review - $165 (please call the main office to make a payment: 503-838-1212)

By signing this form, I certify that the above statements and the statements in the attachments and exhibits transmitted herewith are true. I also acknowledge that any permit subsequently issued on this application may be revoked if it is found that any such statements are false.

Applicants Signature(Required)

Date(Required)

Month

Day

Year

A fee is required for this permit. Please call City Hall for current fee schedule.

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Approval Status

Upon submitting this application to the City Recorder, a police background investigation may be conducted. This form must be completed. Illegible applications may be rejected. Application MUST be signed.

Please choose one:(Required)

Amusement (Device)

Secondhand/Junk Dealer

Entertainment Business

OLCC Dispenser

Auctions/Auctioneers

Please choose all that apply to your business:

w/Dance Floor

Public Dances

Amusement Device(s)*

Social Games

Cigarette Vending Machine

Regular Closing Time:

Number of Dances:

Number of Devices:

* Pool table, billiard table, pinball machine, video game (shall include machines which are part of the operation of the State Lottery), jukebox, card room, card table, shuffleboard, digger/crane machine and any game of skill or chance.

Class:

Applicant Information

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Date of Birth(Required)

Month

Day

Year

Other Names Used (aka's, nicknames or maiden names)

Business Informaiton

Business Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Federal ID Number

Partners or Corporate Officers

Name

DOB

Address

Phone #

Please use the + toggle on the right to add more people.

Producst Being Sold (list type of products being sold - if Auction: please submit an itemized list)

Auction List Upload

Max. file size: 50 MB.

If renting or leasing building or property on which the business is located, please provide owner information & signature.

Owner Name

First Last

Owner Mailing Address

Street Address Address Line 2 City State ZIP Code

Owner Phone

Owner Email

Upload Owner Letter of Signature & Date

Max. file size: 50 MB.

Insurance/Bond Information

Insurance Company(Required)

Agent(Required)

Agent Phone #(Required)

Policy Number(Required)

Effective Date(Required)

Month

Day

Year

Expiration Date(Required)

Month

Day

Year

Professional References(Required)

Company

Address

Name of Contact

Phone Number

Use the + icon on the right to add more references.

I, the undersigned, do hereby give my consent to the City of Independence Police Department to conduct a reference check into the legitimacy of my business and, if applicable, a background investigation for the purpose of determining my qualifications to be granted a license. I do further authorize the release to the City of Independence and Independence Police Department all information pertaining to, but not limited to, my records needed in determining my granting of a business license. I do certify that all statements made here are true with the understanding that omissions of fact or misstatements on my part shall be cause for forfeiture of eligibility for a license.

Signature of Applicant(Required)

Date(Required)

Month

Day

Year

A $220 fee is required for this permit.

Please complete the Agreement for Payment of Land Use Application Fees and email the completed form to fevander@ci.independence.or.us.

Multiple signatures are required; a link to collect additional signatures will be provided after submission.

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Form Type

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Approval Status

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Application Number

General Information

Project Address(Required)

Nearest Cross Street

Tax Map

Tax Lot(s)

Site Size

Site Dimensions

Project Summary(Required)

Property Owner

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Applicant

Name(Required)

First Last

Business (if Applicable)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Applicants Interest in Property

Application Type

A. Structural Details - Activity(Required)

New Structure

Addition*

Alteration* (includes repairs or improvements)

Relocation**

Demolition

Replacement

*An alteration includes the repair or improvement of a structure. If the value of an addition or alteration to a structure equals or exceeds 50% of the value of the structure before the addition or alteration, the entire structure must be treated a substantially improved structure. **A relocated structure must be treated as new construction.

1. Structure Type(Required)

Residential

Non-Residential

Mixed Use

Manufactured Home

Recreational Vehicle

Garage

Other (please specify)

2. Structure Type

Elevated

Floodproofed

3. Structure Type

Attached

Detached

Number of Units

B. Project Components

Clearing

Fill

Mining

Drilling

Grading

Dredging

Excavation or Removal of Fill (Except for Structural Development Checked Above)

Watercourse Alteration

Drainage Improvement (including culvert work)

Fencing

Project Components Cont.

Utilities

Subdivision (New or Expansion) or Partition

Road, Street, or Bridge Construction

Individual Water or Sewer System

Other (Please Specify)

Other (please specify):

Project Details

Please fill out all that apply.

A. Details for anchoring structures (type of anchoring used and location of anchoring):

B. Details of floodproofing or elevation of utilities. Provide the elevation of the utilities or the elevation to which the utilities will be floodproofed. If floodproofed, provide details regarding how the utilities will be floodproofed (describe the type of floodproofing used or manner in which the utilities will be floodproofed):

C. Exact location(s) on structure of all flood openings, if required. Include the elevation of the bottom of the flood opening(s), the size of the openings, and note if engineered flood opening(s) will be used. (Provide a reference diagram, in site plan or drawings):

D. Types of water-resistant materials used below the first-floor and portions of the structure they will be applied to:

E. For alterations or additions to existing structures: Estimate of Cost for Alteration or Addition 1

1 PLEASE NOTE: Cost of construction estimates must include all structural elements, interior finish elements, utility and service equipment, labor and other costs associated with demolishing, removing, or altering building components, and construction management. As well as any improvements being made to repair damage that go beyond just making repairs to return to pre-damaged conditions.

F. For non-residential construction:

Type of floodproofing method:

Required floodproofing elevation is:

feet NGVD

Floodproofing certification by a registered engineer attached?

Yes

G. For projects that alter landforms or change a water course:

Amount of fill to be placed:

Top of new compacted fill elevation

ft. (NGVD29/NAVD 88)

If the proposed development activity will result in a change in water elevation, what is the change in water elevation (in feet)

Required Submittals

Please check off what you have uploaded:

Complete application

Applicable fees

Agreement for Payment of Land Use Application Fees (notarized).

Plans drawn to scale, with elevations of the project area and the nature, location, dimensions of existing and/or proposed structures, earthen fill placement, any watercourse or landform alterations, storage of materials or equipment and drainage facilities. Plans shall include location of all water bodies, adjacent roads, lot dimensions, as well as, delineation of Special Flood Hazard Areas, regulatory Floodway boundaries including Base Flood Elevations (when available), or flood depth in AO zones.

Please check off what you have uploaded:

Copies of all required local, state, and federal permits. All required local, state, and federal permits must be approved before the floodplain development permit is approved.

A complete pre-construction Elevation Certificate signed and sealed by a registered professional surveyor.

Certification from a registered professional engineer that any proposed non-residential floodproofed structure will meet the floodproofing criteria of the City of Independence and Oregon Specialty Code requirements, if applicable.

For projects that impact a mapped floodway, a copy of “no-rise certification” from registered professional engineer or a FEMA approved CLOMR.

Submittal Upload

Drop files here or

Max. file size: 50 MB.

Signatures

THE PROPERTY OWNER(S)/APPLICANT(S) SHALL CERTIFY THAT:

The request does not violate any deed restrictions that may be attached to or imposed upon the subject property.
If the application is granted, the applicant will exercise the rights granted in accordance with the terms and subject to all conditions and limitations of the approval.
All statements above, as well as those included in the site plan, attachments, and exhibits submitted with this application, are true. The applicant(s) acknowledge that any permit issued based on this application may be revoked if any such statements are found to be false.

Signature(Required)

Date(Required)

Month

Day

Year

A $60 notice fee is required for this permit and may require other associated fees.

Please complete the Agreement for Payment of Land Use Application Fees and email the completed form to fevander@ci.independence.or.us.

Multiple signatures are required; a link to collect additional signatures will be provided after submission.

Refer to the Required Submittals Checklist and General Information pages before submitting your application.

Step 1 of 5

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Form Type

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Approval Status

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Application Number

Project Name

Project Address

Applicant

Name(Required)

Business Name

Mailng Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Applicant's Relationship to Property(Required)

Are you the owner of this property?(Required)

Yes

Other (please specify)

Property Owner

Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Does the owner of this property own any adjacent property?

Yes

If yes, please list tax map and tax lots

Additional Personnel

Name

Role

Business Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Property Information

Tax Map

Tax Lot(s)

Frontage Street or Address

Nearest Cross Street

Comprehensive Plan Designation

Zoning Designation

Site Size

Site Dimensions

Does the project qualify for an expedited request?

Yes

Applicant Waives

Is a variance or any adjustment of standards required for the request?

Yes

Please explain:

Proposed Development

Subdivision Type(Required)

Single Family Detached

Duplexes

Single Family Attached (Non Duplexes)

Multifamily

Commercial/Industrial

Number of Lots(Required)

Total Number of Units(Required)

Max Lot Size (square feet)

Min. Lot Size (square feet)

Average Lot Size

Submittal Uploads

Before submitting this form:

Review and upload all required submittal documents
Pay associated application fees as required
Complete and sign the Agreement for Payment of Land Use Application Fees

Download, complete, and submit the required forms via mail or upload them using the section below.

For full details, please refer to the Subdivision Required Submittal Information.

Upload Submittal Files

Drop files here or

Max. file size: 50 MB.

Consent(Required)

By signing this form, I certify that:

1. All the above statements and the statements in the plot plan, attachments and exhibits transmitted herewith are true. I also acknowledge that
any permit issued on this application may be revoked if it be found that any such statements are
false.

2. The above request does not violate any deed restrictions that exist or may be attached to or imposed upon the subject property.

3. If the application is granted, I will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations
of the approval.

I agree to the privacy policy.

Applicant Signature(Required)

Date(Required)

Month

Day

Year

A $60 notice fee is required for this permit and other associated fees.

Please complete the Agreement for Payment of Land Use Application Fees(PDF) and email the completed form to fevander@ci.independence.or.us.

Multiple signatures are required; a link to collect additional signatures will be provided after submission.

Step 1 of 5

20%

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Form Type

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Application Status

This field is hidden when viewing the form

Application Number

General Information

Site Address(Required)

Nearest Cross Street

Tax Map

Tax Lot(s)

Site Size

Site Dimensions

Project Summary(Required)

Applicant

Name(Required)

Business Name (if applicable)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Applicant's Interest in Property(Required)

Are you the property owner?(Required)

Yes

Property Owner

Name

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Type III Action - Application Type - Fee: +$60 Notice Fee

(Should be completed prior to submittal of application)

Land Use Pre-Application (Should be completed prior to submittal of application) - $300

Land Use Actions *

annexation (upload petition to this application) - $2,000*

Comprehensive Plan Map Amendment - $2,500*

Zone Change - $2,500*

Site Design Review (for larger commercial/industrial development) - $500*

Type IV Action - Application Type - Fee: +$60 Notice Fee

(Should be completed prior to submittal of application)

Land Use Pre-Application (Should be completed prior to submittal of application) - $300

Land Use Actions *

1Private parties may request a Type IV action; however, it must be initiated by the Planning Commission or City Council.

Comprehensive Plan Amendments/Revisions - $300*

Master Plan Adoptions

Development Code Amendments

Total Application Fees - NOTE: ALL FEES ARE NON-REFUNDABLE

Required Submittals

Please check off what items you have uploaded.

Details necessary for the proposal as specified in the Independence Development Code.

Legal description of the property as it appears on the deed (metes and bounds). This can be obtained at the Polk County Clerk's office in the Courthouse.

For a Zone Change, Comprehensive Plan Amendment or Urban Growth Boundary change, the names, addresses and zip codes of all the owners of record of the property(ies) to be reclassified, if not shown above.

Agreement for Payment of Land Use Application Fees (notarized).

Would you like the city to supply the list and labels for an additional $25?

Yes - please include $25 to the total due with your application.

Submittal File Upload

Drop files here or

Max. file size: 50 MB.

THE PROPERTY OWNER(S) / APPLICANT(S) SHALL CERTIFY THAT:

The request does not violate any deed restrictions that may be attached to or imposed upon the subject property.
If the application is granted, the Applicant will exercise the rights granted in accordance with the terms and subject to all the conditions and limitations of the approval.
All the above statements and the statements in the plot plan, attachments, and exhibits transmitted herewith are true. The applicant(s) acknowledge that any permit issued on this application may be revoked if it is found that any such statements are false.

Applicants Signature(Required)

Date(Required)

Month

Day

Year

Forms Page

What permit do I need?

Owner or Applicant

Contactor

Fence Description

Required Submittals & File Upload

Fence Permit Requirements

Confirmation

Applicant Information

Water Meter Information

Applicant's Section - Please complete items 1-7

Plan Review Fee

Requestor Information

Owner Information - If different

Property Description

Reason for Address

Requestor Signature

Your Information

Landlord's Information

After reviewing the listed city code, check the box below if you believe your residence may have any of these violations:

Requestor Information

Refund To:

Property Owner

Applicant

Additional Personnel

Project Details

Pre-Application Submittals

Upload Files and Sign

General Information

Applicant

Property Owner

Type I Action - Application Type

Type II Action - Application Type

Required Submittals

General Business Registration

Business Information

Type of Business Information

Owner/ Operator Information

The following Confidential Emergency Contact Information will be used only by Emergency Services Personnel

Signature

Application Fee

Questionnaire

16. What plans do you have for the business in the following areas?

Applicant Signature

Business Information

Fees

Required Information to be Uploaded

Business Details

Applicant

Business Contact at Mobile Vending Site (If not applicant)

Property Owner (If not applicant)

Required Submittals

Signature

Restaurant Details

Planned Operation Details

Applicant

Property Owner (If not applicant)

Required Submittals

Signature

Business Information

For a Crew License application, please complete the following pages for each individual that will be performing the door-to-door solicitation.

Other Names

Previous Addresses

Physical Description

Other Information

Business Information

Insurance Requirements

Other Names

Previous Addresses

Physical Description

Other Information

Property Owner Information

Management Company Information (if applicable)

Complainant Information

Information About Complaint

Detailed Statement

Independence Municipal Code 26-256 Permit Required

Event Information

If a Parade - Estimate the number of entries expected

Please note: