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FOR OFFIC~_?SE~ O/NLY <br />Received By: ~ <br />Zo ng <br /> <br /> MARION COUNTY BUILDING INSPECTION ~ US__E O'N' L~ """1 <br /> , 220,. High Street Ng [ City Satbaek Requirements: ] <br /> ,,,,,)/ Salem, OR9730! [Front: /,~ ]Rea~ ?/~ ! [ <br /> ';, 8:00am - 4 GOt'~'a Phone $$g-$ I47 I Ldt Side: ' I Ri ht Side' ' ~ I <br /> <br /> BUILDING PERMIT APPLICA~I[~ <br />COMPLETE ALL SECTIONS. 1 THROUGH 4 ~ <br />1. Jbb Description ' .~ ~ '2, [~S~: q <br /> <br />2. Location of Installation <br /> <br /> Tax Ac~i. l~o. Cross Street~,~/~ ~e~ <br />~ $i~ N~ <br /> ~ BI~ <br />Range ............... ', ~L~ Map Water 8u~ly: <br /> Private Well ( ) Sp~g ( ) <br /> <br />3. Contractor Information <br /> tOwhee MaillugAddgss ~ ~.~.~g, ~.. ]PhoneNo:T{~..7?5/~ <br /> <br /> : I uodersm~d ~a I must ~s~r as a ~tmcfi~ ~c~ ff ~e s~au~ is s~ or ~emd for a~e before or u~n ~ple~, <br /> <br /> If I hi,c sub*ontra,tor~, l will him only subcontractors ~gister~t with the Constmaion Contractor~ Board. If I change my mind and do hire a general contractor, I witi contract <br /> with i contractor who is mgismmd withe Construction Contractors Boa~, and will immediately holily Marion County of the name of the contractor. <br /> <br />I 09 I am a rcgismmd builder OR I~e authod~d ~pr~ntafi¢e of a registered baildcr. <br /> <br /> 4. F~e Schedule <br /> <br />V~LUATION (Sec "Valuation Schedule" <br />to de~rmine vaiuation based ora <br /> <br />square footage.) <br />(1) Permit F~ <br />(2) 5% Sta~* Surcbargc (.0S x A 1) <br />(~) Structural Plan Review (.65% x Al) <br />(~) }lire & Life Safety Pian R~view (.40% x Al) <br /> <br />V. luailo~: $ J~lgO <br /> <br /> t.q · <br /> <br />B. Migc~llaneOus Fees <br /> <br /> : (1) Driveway w/curb @ $7.50 <br /> (2) Driveway w/o curb @ $17.00 <br /> <br /> (3) Site Plan Review (eanmereial only) @ $79.00 <br /> (4) Additional Plan Reviews or Addendums <br /> (5) lnve,figation Fee <br /> <br /> (6) Reinspection Fee@ $25.00 <br /> <br />I he,by cc~ffy ~at the abow i~o~afi~ is ~ct ~d ~at I have mad ~d un~nd ~ ~afi~ No,ce ~ Pr~eny Ownc~ a~t C~stmcfio~ Responsib~de~ on ~e <br />reverse side of ~iS fora. ~ ~ <br />Name o/Apph~a ~leas~ PrimO:I ..,,,,, ,L C ............. Phone: l <br /> <br /> Sit e ~valua~on s,'sep0c, el~fi~al.~u~g~d m.chanieal wo~ mq~ xe.ratff '~i~. Check wi~ Mad~ County Bmld~g Instal0. 1,2~ sul,mltt~g *is a~hcafion, <br />MC 15-73 Rev, 11/91 <br /> <br /> <br />