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F~OR OFFICE 'USE ONLY I
<br />Received By: /~
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<br />MARION COUNTY BUILDING INSPECTION
<br /> 220 High Street NE
<br /> Salem, OR 97301
<br /> 8:00a'n - 4:30pm Phon~ 588-5147
<br /> Code. A-Pbon~ 558-7904
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<br /> BUiLDING PERMIT APPLICATION
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<br />FOR OF'I~iCE USE ONLY
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<br />~hy Setback Requlremen~:
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<br />zi~:
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<br />COMPLETE ALL SECTIONS, 1 THROUGH 4 I~:JV 1 2 199~
<br /> Descrl ,tlon
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<br /> ( )Addition ( )R~lo~afion ( )Addition ( )Sign
<br /> ( )~m~ ( )D~o~6~ ( )~U~ ( )D~o~6~ C~
<br /> ~),,Access~ ( )~er ( )~eof~u~y ( )O~er
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<br />~( ) or ~t ~ ,,,,,,~ ............... [ No. S~s [ ~co~t ~d or ~m~ ~ ~ees [ NO. Bedrooms:
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<br />2. Location of Installation
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<br />i'l;r°~'~Y0'~I'~[,,,,,,,,,,,~4-1a~ ~o~e~ { M~thg^dd.. '3~ 3 gal ~r~t{{ Im~°' 76~-71qq
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<br />SuMMs~ ~ Bl~k
<br />Se~ 'To~shp ~ge . ~e ~p ' Water Su~ly:
<br /> Private Well ( ) Sp~g
<br />~[Wid~ ~S) ~ ~l A~S i~,~ Comer iCo~,~,}'W~R( ) City
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<br />3. Contractor Iuformation
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<br />()~ I own, reside th: or, will t~iOi i~ the completed shmcmm, : ::
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<br />( )' I UnO,rand that ! must register as a constmctieu commcmr if thdscmettm: ~s ~old Or iaffew~d for ~ale Before or upon compl*tion,
<br />( ) ! will lac my ~w~ general contractor,
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<br />ff I hire sulgontractol-& I will hi~ only subcontractors r~glstered with th~ ConstruoAon Ccmraetors ~oarcl. If I b~tange my mind and do hirc a general contractor, I will COntract
<br />with a eoatraotor who is registered with~ Constmeti~m ContractOr's Board. and willimmedlat&ly no'fy Marion Count) of th~ name of the ¢catractor,
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<br /> (~ I am a registered builder OR t~e authorized represoa&tlve of a ~gistcmd builder. I
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<br />Awhit~t r~ane:
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<br />4. Fee 8clledale
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<br />{ Mailing A~ress:.
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<br />63-/7i I
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<br /> A. VALUATION (~e~j'¥aluatlon Sehedule" B, Miscellaheo~s F~e~
<br /> to d~termin~ valuation based oft ~ /b~ (1) Driwway w/eufo ~ $7.~0
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<br /> squai~ footage.) Valuation: $ -.-~dd fi-'"' (2) Driveway w/o curb@
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<br /> (1> P*~rmitF~ , ~,,,G _~'~ (~) $imPhnReview (commemlalc~ly)@ $79,00
<br /> (2) $t Sut~ Suaarge 605 × ~'1) · ~'~LY' (4) A&lifional Plan R,views or Add~dums
<br /> 0) Stmcmnd Plan Review 665% x Al) ' ~- : - (5) Iav~stlgation F~
<br /> (4) Fire & Life Safety Plan R~vinw (,40% x A1 ) ; (6) Reinspeetica Fee @ $25.00
<br /> (5) ZOuing Surcharge, if appllcgl~le (,05% x A l ) = (7) Other ~$~ctims not lisU~d above
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<br />I hereby eer[ffy that the above informat~o~ comet and that~have mad and under~tand the Information Ncd. ce to ProI'~y Owners about Cona~mcfion Responsibilities o~ the
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<br />Site evaluations, septic, electrical, plurabing and mechanical work r4quive seperate permits, Check with Marion County Building Inspection kfore submitting thh application.
<br />MC 15-73 Rev, 11/91
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