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FOR OFFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION FFOR OFFICE USE ONLY <br /> <br />220 High Street <br /> Salem, OR 97301~ff <br /> <br /> BUll,DING PERMIT APPLIC/[/i~~ <br />COMPLETE ~L SECTIONS, 1 T~OUGa 4 BUILDING IN P[{TION <br />1. Job De~ription <br /> <br />RESIDENTIAL COMMERCIAL ( )New Usc~ of Stmctu~: <br />( )Adthfio. ( )R~location ( )Addition ( )Sign ~..-~<g0 ~ <br /> (v~Mtevafion ( ) Demolition ( ) Alteration ( ) Demolition <br /> ( )AccesseD, ( )Other ( )ChangeofOcculmncy ( )Other <br /> <br />) / {O¢¢upantLoadorNumber.ofBmployees No, Bedrooms ~ ...................... <br />Squamr=t~.-.gasement: {M~inFloor: 2V~' Is~n~': [Other: Height: ~ ~'' <br /> <br />2. Location nflnstallation <br /> <br /> / Sim No. <br />Mob~e H~e Park S~ <br /> Private Well <br />Lot Width 2 ~ 0 / ~t Depth ] 0 0 / Acres I.eg. ~t Comer <br /> <br />3, Contractor Information <br /> <br />Prol0erty Om)er [" Mailing Address I Phone No: <br /> <br />(~<~ I own, t~sid~ ia, or will reside ia the completed armoire. <br />~'~) I u/idemtand that I must regis~r as a construction contractor ff the structure i~ sold or offered for sale before or upoa completion, <br />~) I will be my own general contractor. <br /> <br />If I Nm subcontractors, I will hire only subcontractors registered with the Comtmofioa Contractor* Board, If I change my rrdnd and do hlrc a general comractor, i will contract <br />with a contractor who is re,~stered withe Construction Commetogs Board, and wlllimmedi~tely notifgz Ma~on Count7 of the name of the contractor, <br /> <br />Contractor Business nme & #: [ Marling Address: I Phone: <br />Architect name: I Mailing Address: ,I Phone: <br /> <br />4, Fee Schedule <br /> <br />A, VALUATION (See "Valuation Schedule" · <br /> to detem~iae valuation based on <br /> square f~x~tage.) <br /> (1) Permit Fee <br /> <br /> (2) 5% State Surcha~e (.05 x Al) <br /> O) $tmctoral Plan R~view (,65% x Al) <br /> (4) Flee & 10ifc Safety Plan Review (,40% x A 1 ) <br /> <br /> B, Miseellaneoa~ Fees <br /> <br /> (1) Drivewayw/¢urb@ S7.50 = __ ......... <br /> Valuation: ~'~gl~l~O 0 (2) Dfivewayw/oc,rbC~ S 7~ <br /> ~--~"~ O) Site Phn Refiew ¢~mercial mly)~ svg.m <br /> = ~ ~ ~ (4! A~fi~a} Plan R~ews or Addepdums <br /> ~ ~ .~' 0 ~ (5) hvesfigafim Eee <br /> {6) Reiai~etlon Fee ~ $25.00 <br /> (5) ~ning Surcha~e. if appliaable (.05% x A l ) ~) O~er ~s~s not lift,al.above e,~) =~ <br /> <br /> hereby cenlfy ~at the above iMo~afiml is ~=t ~d ~at I have read and undemmnd ~e I~ fo~ati~ No,ce to Prope~70wner~ ith~t Cmstmcfion Responsibilities on the <br />reverie side of ~is fo~. <br />Name of App'cant ~,ease Print): d~'~ ~' ~ Phone: ~~~'' <br /> <br /> .Site eva[ua0~s, s~phc, electrical, plumbing ~d mechanical wo~ mq~m so.mm ~mlls. Check wi~h Marion County BulldNg Impe~ion ~fom mbmlltiag Ibis application, <br /> <br />MC 15.73 Rev, 11/91 <br /> <br /> <br />