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IFOR OFFIC~ ,.,US~0~4.LY MARION COUNTY BUILDING INSPECTION FOR OFFICE USE ONLY <br />Received By: ~ 220 High Street NE ci~ S~tbac, k Reqldr~xn*nts: <br /> Zoning?ahdation- c~O/,~ Salem, OR 97301 F~t~t: Rear: /~// <br /> Date: · lb' =.~2.. ?~3 8'00ara-4'30rnnPhone$88-5147 Pi~'~_ Le~tSi,~ // '/'' <br /> B UILD1NG PERMIT APPLICAr~N~ <br /> <br />2. Location of Installation <br /> <br />Pr~.yOwner .~O.~Jc,¥A_~..~ ~)n.,~) .................... [Ma~gAddmss ~ ~,[~ CCe~k .............. ~?neN°'7~2~q <br /> <br /> IA~.Pc~ 0,~- ~7~z5 s~o. , ..................... <br />$u~ivi~ion ~ Bilk <br /> ' PHvamWe][ ( )SpHng <br />L~d* ,~:qf ..... L~Depth )OO' AC~s ............... I~g.~t ]Comet CommuMtyW~( ) City <br /> <br />3. Contractor Information <br /> <br /> ~I o~, ~, ~ c~pleted stratum. <br /> me <br /> <br /> ( ) I will ~ my o~ gme~ ~tm~, <br /> <br />v~th a contractor who ia registered withe Construction Ceotraeto[s Board, and willimmediately notify Marion Coumy of the name of the conrxactor. <br />C°ntract°rBustheaaname&#:~n~- ~-~,'~.~¢ ]MailingAddmss;~t'~ t}a.l{e,~~Ph°~; 3L, 3-17l[ <br /> I am a regismmd builder OR'he authorized repre~mafive of a ~gist~red bulmer. I <br /> <br />4. Fee Schedule <br /> <br />A. VALUATION (Sec "Valuation Schedule" <br /> to dOterra~¢ valuation based on <br /> squam footage,) <br /> <br /> 0) Permlt Fca <br /> <br /> (2) 5% S~e Surcharge (,05 x Al) <br /> <br /> (3) Straemral Plan Review (.65% x Al) <br /> <br /> (4) Fire & Life Safety Plan Review (A0% x Al) <br /> <br /> (5) 7~rdng Suteha~e, if appl~eablc~ (,05% x A ! ) <br /> <br />B. Miscellaneous Fees <br /> (1) Drlveway w/cueo @ $7.50 <br /> <br /> (2) Driwway w/o ¢~rb @ $17,00 <br /> <br /> (3) Site Plea Review (commercial only) @ $79.00 <br /> <br /> (4) Additional Plan Reviews ot Addendnms <br /> <br /> (5) ~'~esilsatiOn Fee <br /> <br /> (6) Relnspecilen Fee @ $25.00 <br /> <br /> (7) Other ~specg,ons no~ hsted above <br /> <br />I hereby certify that ~he above information is cor~et ~md that I have ~ad and understand the Information Notice to Property Owner~ about Construction Responsibilities on the <br />reverse aide of this fSrm. <br /> <br /> ~ cvaluatlon~, ~eptlc, el~c rlca], plun~m~ mqui~ separate p~rmi s. y B tdldin§ In~pec 'ubmittthg thi¢ apphcation. <br />MC lf-73 Rev. 11/91 <br /> <br /> <br />