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IFOR OFFICE USE ONLY <br /> Received By: -- <br /> Zoning Validation: <br /> Date; <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> g:0Oam - 4:30pm Phone 588-5147 <br /> Ca~e-A.Phone 588-7904 <br /> FAX 588-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br /> <br />1. Job Description <br /> <br /> E ONLY <br /> Right Side: <br /> <br /> RESI~ENTIAL COMIVIERCIAL ( )New Use of Structure: <br /> ( )Addit,[on ( )Rdoca6.on ( )Addilion ( )Sign )~/o/~ <br /> ( ) Alteration ( )DcmoUfie~ ( )Alteration ( )Dr~nolition <br /> ( )Acccsso~ (2~)Othcr ( )C~angcofOc~upancy ( )Other <br /> Description of Work: <br />' Tress ~ or Rafter ( ) [ No, Stories ~ I Oc~upam Load or Nttmber of Employees ,,~2~_ , ....... ~4,9,,.~?. r?oms: ~ <br /> <br />2. Location of Installation 7c~-k_,~ ~ {DLE~ .... <br />Si~ No. <br /> <br />$u~s~ L~ BI~ <br />~o~c ~omc Pa~ S~ ~ <br />S~n TomsMp R~gc ~c Map Water Supply: <br /> Pfivaze Well ~ Sp~g ( ) <br />~[Wid~ //7/ LotDeplh ~O' Acma I~g.~[ Comer Commu~tyWeB( ) CJty ( ) <br /> <br />3. Contractor Information <br /> <br />( ) I undcnmnd ~at I must m~s~ az a mnstmcfim contractor ff ~e stm~u~ is sold or offered for s~* before or u~n ~ple~. <br /> <br />( ) I wi~ ~ my om gmeml c~tm~t <br /> <br /> ( ) I am a registered builder OR the authorized mpr~s~ntailve of a registered buLMer, <br />Amhitect narae: ~-¢~.45'- [-.r/C2~' 'lMail/ngAdd~m <br /> <br />4. Fee Schedule <br /> <br /> A. VALUATION (Sec "Valuation Schedule" B. Miscellaneous Fe~s <br /> to determine valuatioll b~seti c~l (1) Driveway w/curb @ $7.50 <br /> square footage.) (~[~ Valuation: $~ · I~ ¢2) Driveway w/o curb @ $17.00 <br /> (1) Pen~it Fee '~ ~ (3) S~tc Plan Review (commereAal only) ~ $79.~ <br /> <br /> (4) Fim&,UfeSafetyrlanReview(.~%xAl) = --1 I OD (6) ~s~mF~ $25.00 <br /> (5) ~mng Sumha~e. if applicable (.05% x Al) ~ I* e) O~er <br /> <br /> pp ~ ~v . ~nrr¢ .......... <br /> <br />MC 15-73 Rev, 11/91 <br /> <br /> <br />