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[-FOR OFFICE USF~ ONLY <br /> <br />I zoning Validation: <br />I Date'_ <br /> <br />MARION COUNTY BUILDING iNSPECTION <br /> 220 High Street <br /> Salem, OR 97301 <br /> <br /> ~:00am - 4~30pm Phtmc 588-5147 <br /> Codc. A-~l~.e 588-7904 <br /> FAX 588-7948 <br /> BUILDiNG PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 TI-IROUGH 4 <br />I. Job Description <br /> <br />RESIDIhN'rlAL ( )Relocation COMMERCIAL ( )New <br /> <br /> ( )Addition ( )Addition ( )Sign <br /> (~Aheration ( )Demolition ( )Ahetalion ( )Demolition <br /> (~A¢ccssoqt ( )Othcr~c~(.,,.,~//~,c,~ ( )ChaageofO~upaney ( )Other <br /> <br />Square Fe~t: Ba$~m~em: I Maha Fl~Or: <br /> <br />~R OFFICE USE ONLY <br /> ,~t: / R~. [' / <br /> tSiOe- mshtSide...$'/ <br /> <br />I O~ul~mt Lead or Number of Employo~s N~, B~dr,-~ms: <br /> I Sec;md Floor. [ Other: ~?(=.,,~. ~ ~ Height: <br /> <br />2. Location of Installation <br /> <br />Prot~ny Owner <br /> <br />Job Address 1~0 T~,~(~ <br /> <br />Suhtivision ~ <br /> <br />[MailbagAcld~ss ~cx~ rat// D~_~'~o~?" <br /> <br />Tax Aect No, ~6 ~,:~ -- ,e-/,°O <br /> <br />Site No. <br /> <br />[ I Tow~ahlp IO-'c Raage .~ 6 Zca~ ~$' cM;mPer <br />.5-0' ,0o' 1^o;,, <br /> <br />phone No. <br /> <br />Water Supply: <br />PtivateW¢}[ ( ) Spring <br />Co~.,mun~ty We~ ( ) City <br /> <br />3. ContraCtor Information <br /> <br />willt~ my owa gemerA ¢,mtmct~. <br /> <br />Contractor Buainess nam~ & 8: ~aeeV U,O, ~J~,,d co~m-. ~c~-ioht I Ma~Ii~g Address: Fo ~.¥ -~'~.~- {Phone; <br /> <br />Architect name: [ Mailing Add~ess: 1 Phone: <br /> <br />4, Fee Schedule <br /> <br />VALUATiON (See "Valuation Schedule" <br /> <br />square footage,) ~(o2 .~f ~- <br />(1) Permit Fee <br />(2) 5% Sram Surcharge (.05 x Al) <br /> <br />(3) Sml¢tund PLan Review (.65% x A I) <br /> <br />(4) Fire & life Safety PLan Revi*~v (,¢0% x At) <br /> <br />(5) Zolting Surcharge. 'f applicable (.05% x A 1 ) <br /> <br />Valuation: $ I )q(5~ O0 <br /> <br /> = ....I .33 <br /> <br />(I) Driveway '.',kurb @ S7.50 <br />(2) Driveway w/o curb ~ $17,~ = <br />(3) Si~ PLan Renew (commercial only) <br />(4) Additional Plan R*view~ or Addendums = ....... <br />(5) ~vcs~ga~ Fee <br />(6) Rclas~m Fee ~ <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />