Laserfiche WebLink
FOR OFFIC~ ,USEg~I~Y <br /> Received B,y: ~, <br />I Zoni.g VaUda ion: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:00am - 4:30pm Phone 588-5147 <br /> Code-A-Phone 588-7904 <br /> BUILDING PERMIT APPLI~[rl~)I~ <br /> <br />FOR OFFICE USE ONLY <br />City Setback Requiremem~; <br /> <br />Front; /to / Rear: /0 <br />Left Side: Right Side: <br /> <br />COMe~LETE ALL SECTIONS, <br /> 1 TI-tROUGH 4 <br /> <br /> L Job Description <br /> <br />RES[DHNTiAL COMMERCIAL , ( )NewMA~iQN Ol)[~'[~/stt0cttlre; <br />( )Addition ( )Rd~afi~ ( )Addition ( )~ILDING INI',~ ~0~ s~ <br /> ( ) Alteration ( ) Demo~fi~ ( ) Almmfion ( ) Demo~fim ] ~ ~ ~ ~ <br /> ~)Aeeesso~ ( )O~er ( )~a~eofOceu~ney ( )O~er , , <br /> <br />Tress( ) oeRaner( ) INo. Smfies ]Oceu~tLmdorNum~ofEmployees INo, Bedrooms: <br />I H r: ] Semnd ~r: [ Other: I He.ight; <br /> <br />2. Location of Installation <br /> <br /> [ Sim No, <br />Subdlvisim ~ g [~k <br /> <br />Section dS~ ............. 'l~w~S~p ~ Range ~ ~ ~ Ma~ -- WalerSopply: <br /> PrivateWell ( ) Spring ( ) / <br /> <br />3. Contractor Information <br />Pmpe~y Owner (?-~f't~. ~Z*-: <br /> <br />own. ~side in, or ~i~l reside in the completed structure. <br />undemand that I must register as a eotlstmction contractor if the ~tructum is ~old or offered for sake before or upon c~npteti<m. <br />will be my own general contractor. <br /> <br />CoutractorBu~mes~nttme&#, (~.~ JOr"'~ &~Q~L IMaillngAddms~:~"~S (~Oao~.tM_5'lg'- )'hone; 3{ 3~l?~t <br /> ~ Iam a reglstemd build.,~r OR authorivx~dte-t:,~sentative of, reglst~md b~de~, ~ i,~,,-}~ $ ~,[~, 0~, q7>o ~ <br /> <br />Fee Schedule <br /> <br />A, VALUATION (Sec "Valuation Schedule" <br /> to determine valuation based on <br /> square footage,) <br /> (1) Permit Fee <br /> <br /> (2) 5% State Surcharge (,05 x Al) <br /> <br /> (3) Stmeturat Plan Review (,65% x Al) <br /> <br /> (4) Fire & Life Safety Plao Review (.40% x Al) <br /> <br />, , (5)~7xmlng ~~.', ' <br /> <br />B. Miscellaneous Fees : <br /> <br /> (1) Driveway w/curb @ $T50 <br /> <br /> ¢2) Driveway w/o curb ~ $17.00 <br />"~ (3) Site Plan Review (commercial only) (q) $79.00 <br /> (4) Additional Plan Reviews or Addendums <br /> ,(5) Investigation Fee <br /> (6) Re[nspectioa Fee @ $25,00 <br /> <br /> (7) Oth~r Inspections not listed above <br /> <br />'ro'r.g~.. s 7~ ~ ? <br /> <br />i hurchy certify that the above [nfomlat~on is correct and that I have read and understand the In fommtlott Notice to Properly Owners about Cimstraction RcsponsthiIiIie~ on <br />reverse side o~,this form. <br />N, amc o/Applicant (Plea,se print):/t) C~>b~' ' ~/J" .~J Phorle' <br /> <br /> Site evaluations, septic, electrical, plug and mechanical work mqtdm serrate pomita. Check w h Mar Cou y I] 11 ng I spucx n ~f m ~ bm' 'ng h' ppi'cat'on· <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />