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MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> g:00/ml - 4:30pm Phone 585-5147 <br /> C~-A-~ ~88-7904 <br /> F~ 588-7948 <br /> <br />COMPLETE ALL SECTIONS, 1 TI{ROUGH 4 <br /> <br /> FOR O~F~CE USE ONLY <br />I City Setback Reqtdrevnents: <br />[~,, 1/, , _Rear,/~, ,' <br /> <br />Location of Installation <br /> <br />Job Addmsa } ,,, <br />Subdivls~ ~ Bl~k <br />Se~ Townshp Range ~o Map Wa~r '&upply: <br /> Pdva~ Well ( ) Spring <br />raWid~ ~%j LaDem ~q Ams I=g,~ Comer Commu~tyW~( ) CiW <br /> <br /> Contractor Information <br /> <br />~I own, in, ~- onmpleted ~tm~ur~. <br /> will <br /> in <br /> ) I understand that I mint register as a eonstxucrion eommetor ff the ~tmetuv* is sold or offered for sale before or upon complelfion. <br /> <br /> ) I vrill he my ov,~ general oontraetor, <br /> <br /> If I him subcontractors, 1 will hire Only subcontractor~ registered with the Constwcfion Cmtraetors Board, Iii change my mind and do hire a genera{ contractor, I will COntract <br /> with a ec~traetor who is reglstemd withe Construction Contractor's Board, ~nd will immediately nofffy Marion County of the name of the contrataot. <br /> <br />._ ~ I ama regi~,e'red build,r OR thC'authorized mpla,~ta~v¢ ora r~gi,~ builder, r <br /> <br />4, Fee Schedule <br /> <br />A. VALUATION (See "Valuation Schedule" <br /> to determine valaation ba~ed on <br /> squ~ fOOtage.) <br /> (1) Pemlit F~ <br /> <br /> ~) 5% Sm~ gureha~e (.05 x Al) <br /> <br /> (3) ~twcgur41 Plan Review (,65% x A1 ) <br /> (4) Fire & Lif~ Safety Plan Revi*w (.~o <br /> (5) 7~fing Suwh~e, if app~cchle (,05% <br /> .... <br /> <br />Valuation: <br /> <br />B- MiscellaneOus Fees ~ (1) Driveway w/curb ~ $7,30 <br /> <br /> ~) Driveway w/o cu~ ~ $1~,~ <br /> <br /> (3) Site Phn Redew ¢~me~l <br /> <br /> (4) AddMonal Plan Renews orAddmdms <br /> <br /> (5) ~vesfiga~ Fee <br /> <br /> (6) ~e~on Fee ~ $2~.~ <br /> <br /> (7) Other ~¢~n~9~ not listed above = <br /> <br />i hereby cenif7 that the above i~o~afion is ~ot ~d ~at I ~ve mad and unde~d ~e ~fo~afi~ N~c~ to ~openy Owne~ ab~t C~tmcfion Re~p~ib~fie~ on ~e <br /> <br />MC 15-73 Rev, I1/91 <br /> <br /> <br />