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MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> g~00ara - 4:30~m Phone 588-5147 <br /> Code-A-Phoa~ 588.7904 <br /> FAX 5811-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br /> <br />1. Job Description <br /> <br />FOR OFFICE USE ONLY <br /> <br /> jr' IR r: /d' <br /> , ghtS dc: /0' <br /> <br />RgSIDE.NVlI~L COMMF. KCIAL ( )New Use of St~¢tum: <br />( ) Addifi~ ( )Rd~aO~ ( )Addi~ ( )Sign ~ <br /> <br />2. Location of Installation <br /> <br />Subdivision Lot Block : <br />Sccfion , ,, Township Rsmg~ ZOn~ Map Watc'r S0pply: <br />Lc~Width ~ \ Lo;Depth II,~ A~e~ X~g. Lot I ¢o~.er p~valeWat ( ) spri,~g ( ) <br /> Cmmm~gy~ea ( ) City ~) .. <br /> <br />3. Co~tractor Information <br /> <br /> (~ I o~, ~slde ~; Or ~ ~fide ~ ~c ~pl~led stm~u~. ' ' <br /> ( ) I un~emmnd ~a: I mint m~s~ a~ a c~s:mcdm cm~cwr ~ ~e a~um is ~old or offend for,~e b~om or <br /> ( ) I wiR ~ my own gmc~ <br /> <br />ContracmrBusine,snarn,&#:) a~r~ -~t~ro~, ~,~-~ [MailfllgAddress: % ~q /b~t., ~'{'I~-/~ IPh°ne; Se~2~-7 <br /> <br />4, Fee Schedule <br />A. VA£uATIoN (5~e "Valu~6on S~h~dule" <br /> <br /> squ~ f~ge.) <br /> <br /> ,(I) Pemit F~ <br /> <br />(1) Driveway w/eu/o @ $7.50 <br />(2) Driver)ay w/o eu~o @ $17.00 <br /> <br />C~) Site Plan Review (¢~nmerciaI only) @ $79.00 <br /> <br />(2) 5% State $~Jrchaqle (.05 g Al) <br /> <br />(3) Slmgmral Plan Review (,~% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(5) ?~lniog Sumharg¢, if applieablo (.05% x A 1) <br /> <br />oT-,.v-, ~3 <br /> <br />(4) Additlonai Plan Reviews or Addendums <br /> <br />(5) In'~esfigat~on Fee <br /> <br />(6) RethSl~Ctlon Fee @ $25~00 <br /> <br />(7) Other Inspeedonsnot listed above <br /> <br />I hereby certify that the above bfformatloJ~i* cx~rmct arid that I hav6 read and understand th~ Inforo~fion Notice [o Properly Owners about Construction Respons hilities on the <br />reverse ~ide of this f o~tm. <br /> <br />Na,))e of Appllean~ CPlease prinl): [(l?j f'~4_~, ~l~t d-g Phone; ?[~q - Y ?t{ t[ <br />Signature of Apptisan ¢~4~ ~_ )ate: ~ <br /> Sile evaluations, septic, elcctrleal, plumb~g and mechanical wo~ rcqtdm se~m~ p~its. Check wi~ Marion Coonty Building Inspection ~fo~ ~ubmitt~g ~is app~ca~on. <br /> <br />MC I5-73 ~. <br /> <br /> <br />