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FOR OFFICE USE ONLY <br /> Re. iv ~I By: __ <br />I Zoning Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION [FOR OFFICE USE ONLY <br /> 220 High Street NE icity Sethaek Requirements: <br /> Salem, OR 97301 <br /> Front: <br /> S:00am - 4:30pm Phone 588-5147Code.A.Phone 558-7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMrr APPLIC~I~ <br />COMPLETE ALL SECTIONS, 1 THROUGH <br /> <br /> i, Job Description <br /> <br />2. Location of Installation <br /> <br />PropcrtyOwner ,.~l,r,vJr(~% [40}'uke~,, IMmli~gAdd~lt~73 ]~d~ CC~t~ <br /> <br />$u~fvlsion ~ Bilk <br />Scion Towns~p Range ~e Map Wamr Supply: <br /> PfivamWell ( ) Spring <br />~Wi~ [~.g5 ~tDc~h &0~ ~c~s ~g.~t Comer Commu~tyW~U( ) City <br /> <br />3. Contractor Information <br /> <br /> (~ I om, msld* ~, or ~I msid* ~ th* ~mpleted stratum, <br /> ( ) I un~grsnnd ~at ~ must m~sgr ag a ~matm¢fim e~ctor ff fie s~um is sold or offered for sale bcfor¢ or u~n ~mpl~fim. <br /> <br /> ( ) I wi~ be my o~ gmgnl ~tm~or. <br /> <br /> hire subcontractors. I will hire only subcontractors n~gi~t~ with the Constmctlon Ccmtractors Board, ~f I change my mind and do lake a general contractor, I will contract <br /> <br />with a ¢;°n~racI°r wh°is ~gis~e~d wlthc C°nstrucfi°n Cnen'tr'a'e~°~'' t t ' " ~O[ ~{~"-°ara'~d will kamediately no~y Marion Coumy nf the name o£ the contractor... (~ I am a registered builder OR the authorized mpresentatlv~ of a ~gi~i~rcO builder. .... <br /> <br />4. Fee Schedule <br /> <br />A, VALUATION (See "%Iuaton S&edule" <br />to de~nnine valuation ba~ed on <br />square footage.) Valuation; <br />(1) Permit Fee <br />(2) $% State Surcharge (.05 x Al) <br />(3) Sm~cmral Plan Review (,65% x Al) = <br />(4) Fire & L/re Safety Plan Review (.40% x Al) = <br />(5) Zon, ng Sum~arge. if apphcable (,O5% x Al ) = <br /> <br />[Mail,iegAddms,: ~.,~-O~/ ~eq <br /> <br />[Phonet ~(~3_~7t I <br /> <br />B. Miscellaneousl~S ........... <br />(1) Driveway w/cuzb @ $?,$0 = <br />{2) Driveway w/o cu~ ~ $17,~ = __ <br />~) Site Hah Re~cw (c~me~al ~Iy)~ $79,~ = <br />(4) Addiilonal Plan Renews or Addmdms = __ <br />(5) ~vesfiga~m Fee = <br />(6) Rc~s~¢6~ Fee ~ $25,00 <br />U) ~¢r~s~ norhsted above <br /> <br />I hereby certify that the above informailOn is comet and that ! have read and understend the Information Notice to ProperLy Owners about Coostr0ction Responsibilities on the <br />reverse side Of ,his form. , ¢,~ (4 ~{fl~- ~ Phone: 7 ,oCl _'??,c~ <br />N~],m. e of Applicant (Please P~)' <br /> Sile evaluations, septic, electrical, pl(m3g ~qd mechanical work mqu~re sclx:rate permits. Check w~th ManOn Coun I)ale; (~ O ~' ~1 ~Otg{ '~ . <br />Signa}um~i Appl/eant: ~{ (~ ................ . ' '' tV Building Inspectlon before mbmitting lhi$ appllcafion, <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />