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OFFICE USE ONLY <br />ived By: -- -- <br />ng validation: ~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:~lOa~a - 4:30pm Phone 588-5147 <br /> Code-A-Pboae 588-7904 <br /> FAX 588-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />FOR OFFICE USE O .N. LY <br /> <br />Left Side; / Right Side: ............... <br /> <br />L Job Description <br /> <br />ii[~SIDENTIA L COMMERCIAL ~ New Use of Sttu~r*: <br /> <br /> ( )Addito~ ( )Rdocation (')Addition ( )Sign <br /> ( ) Access~ ( )~er ( )C~angeof~u~cy ( <br /> <br />2, Location of Installafion <br /> <br />Su~si~ ~t Bilk <br />Mobile B~e ~ S~ce g <br />Se~ ]Z To~a~p 105 ~g~ ~ ................ ~e ~ Map I~ WamrSu~Iy: <br /> ........ PfivamWe]l ( ) Sp~g ( ) <br />~Wid~ ~Da~ Ac~s ~g.~t Coruet C~mu~tyW~( ) ~ty, ,~,, <br /> <br />3. Contractor Information <br /> <br />( ) I ~nd ~at I mus~ ~s~r as a coastm~ c~ ~ ~a stmmum is sold or offend for sale befo~ or u~n c~plefi~- <br /> <br />Coat*actor Business name & #: [ Mailing Addgss: [ Phone: <br />( ) I am a r~gist~md budder OR the authorized npresentatlve of a registered bnildet. <br /> <br />4. Fee Schedale <br /> <br />A, VALUATION (Sec "Valuation Schedule" <br /> <br /> square foomge.) <br /> <br /> (1) Pein'dr Fe~ <br /> <br /> (2) 5% State Surcharge ¢05 x Al) <br /> <br /> (3) Structural Plan Review (.65% x Al) <br /> <br /> (4) Fire & Life Safety Plan Roview 640% x Al) <br /> (5) Zoning Surcharge. ff applicable (.05% x Al) <br /> <br /> -- ~. B, Miscellaneous Fees <br /> ~(~ ~? (1) Drlveway w/omb @ $7.50 <br />Valuation: $~ ~ o~) Dfivewayw/o~urb@$17,00 <br /> g, ~'c~D (3) Sim Plan Review (¢ommernialonly)@ $79.00 <br /> = ~ [ ~C 0 (4) Additional Plan Reviews or Addendums <br /> <br /> = (7) Other htspections not hst~d above <br /> RECF~, <br /> <br />: qq c <br /> <br />I hereby certify that the above information is correct and that I have read ~nd undemtand thc Informatlrm Notice to Propertg Owners about Construction Respc~slbilltles cm the <br />mvcv~e side of this form. <br /> <br /> i' i / ........... <br /> Site evaluations, septic, el .ex,%fieal, plorubidg and mechanical work requlm sepemm permlt~, Check with Marion County Flnild|ng Inspection I:~fore submit6ng thi~ application. <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />