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MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem. OR 97301 <br /> <br /> 8:00am - 4:30pm Phone 588-5147 <br /> Code-A-Phon* 588-7904 <br /> FAX 588-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1, Job Description <br /> <br />IFOR OFFICE USE ONLY <br /> <br /> City Setback <br /> Front: / / <br /> <br />RESIDENTIAL COMMI~RCIAL ( )N~w Use of Structure: <br />( )Addition ( )Relocation ( )Addition ( )Sign <br />( )Al~tation ( )Demolitlrm ( )Alteration ( )Demolition <br />......... ()~,,5,~.,,!,Eo.,. ............................ (,,,) other ( )c~.,g~ of o~.p~y ( ) other <br /> <br /> Tm,( ) or ) I No.$,o e, No, Bedrooms: <br /> Squa~ Feety0OBa~ement: [..M....m~....~.~ [ Second Floor: I Other: He/gat: <br /> <br />2. Location of Installation <br /> <br />3. Contractor Information <br />Property Ownei- _~O ~r-~'O f~ a r. ~/7'~.0 [ Mamg Add~s ' ' ...... <br /> ~I ms~e ~, or wffi msMo ~ ~c ~mple~ stmau~. <br /> om, <br /> <br /> ( ) I ~dc~mnd ~at I mint m~s~r as a c~slmc~ c~cmr ~ ~c s~um ~* sold or <br /> <br /> ( ) I wffi ~ m~ own g~e~ <br /> <br />If I him subcontractors, I will hire only subcontractors registered with lhe Construction Contractors Board. ~ I change my mind and do hire a general contractor, i will contract <br />with a contractor who is registered withe Constmcticll Contractor's Board, and willintmediaW. Iy notify Marion County of the name of the ¢on~ractOr. <br /> <br /> ' · ,.,rt,,, % / I, I ' ¢lZ' gZt/l~,- ~ood ~13-IY/f <br /> ~) I am a reg!~!~red builder OR, the authori.~d mpre/entalive of a registered build.~. ' <br />Arelli 'tqm[name: .~[~ IMailingAd~sst,~-~0~ ..,.[P.hone: 36)~1~111 <br /> <br />4. Fee Schedule <br /> <br />A, VALUA'E[ON (See "Valuation Schedule" <br /> <br /> squam footage.) <br /> <br /> (I) Pema Fee <br /> (2) 5qo State 8~reba~ge (.05 xA1) <br /> <br /> (3) StrUeturA Phn Review (,65¢0 x A1 ) <br /> (4) Fire & Life Safety Plan Review 640% x Al) <br /> (5) Zoning ~/~charge, if applicable (.05% x Al) <br /> <br />(1) Driveway w/cufl~ @ $7.50 <br /> <br />(2) Dfivewayw/ocutb@ $17,00 <br /> <br />(~) Sim Ban Review (emmemial rely) <br /> <br />(4) Agdi~onaI Plan Renews or Addmdums <br /> <br />(5) ~ves~gati~ <br /> <br />(6) R~s~efi~ Fee ~ $2~.00 <br />~) Omer ~s~ons no* hs~d above <br /> <br /> ' Y ' ' " ion Notice to i ropeay Owners about C ms mctio ~ Respcmsibil/fies on thc <br />reverse side of this forgL ~ / <br /> <br />MC 15-73 Rev, 11/91 <br /> <br /> <br />