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COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br />8:00amG~d-e4_ :A~ 0pm. FhonPe ~h~.798504'5147, ltEgEl /Ei} <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLIO~Ti~fq!c<~ <br />COMPLETE ALL SECTIONS, I THROUGH 4 ~'/~J{J~q C~[/~'¥ <br />1. Job Descri )tion BI/Rill <br /> <br />RESIDENTIAL COMMERCe. AL ()New ...... r~ <br />( )Addition ( )Relocation ( )Addition ( )Sign <br />( ) Alteration ( ) Demolition ( ) Alteration ( ) Demolition <br />( ~eCe*soo~ ()Other ( ) Change of Occupancy ()Other <br /> <br />T~ss(~ otRaf~r< ) {No.$tori~ / J [OeeupamLead'~rNamberof~mplo~ No, BedrOoms:ff <br /> <br />2. Location ol Installation <br /> <br />3. Coatractor Information <br /> <br /> ( ) I undemmnd ~al I must ~$~r as a c~stmc~ ~t~r ff ~c ~um is sold or off:md for sMe b~om or u~n <br /> <br />wi~ a c~ctor who i$ m~smmd wi~e C~$tmcfi~ C~c~fs B~M, ~d wffi medh~y n~ Mum County of ~g name of ~ cmtractor, <br /> <br /> ( ) I am a mgls~ bo~d~r OR ~e au~o~d mpmsm~five of a mgis~ b~l~. <br /> <br />Fee Schedule <br />VALUATION (S~ "Valuation Sehedul~" <br />to dctermille valuation based o~l <br /> <br />square fooh'lg e.) <br />(1) P~nnit Fee <br />(2) 5% Sta~ Surchaeg~ 605 x Al) <br /> <br />~) ~tm~RIral Plma Review (.65'~ x Al) <br />(4) Fire & Lif~ $~f~ty P~n R~v~w (,~ X A1 ) <br /> <br />B, Miscellaneous l~e~s ' <br /> (I) Driveway w/curb@ $7.50 <br /> (2) Driveway w/o curb @ $17.~ <br /> <br /> ~) ~m PI~ R~ (cmm~ rely) <br /> <br /> (4) Addifimal Plan Reviews or <br /> (5) hvcs~gafi~ Fee <br /> (6) R~s~cd~ Fe~ ~ <br /> U) O~er ~cdons not ~s~ a~ve <br /> <br />i hereby certify that the above information is cermet and that I have read and undernand the I~formafion Notice to Property Owners about ConstmcLio, Responsibilities on the <br />reverse side of this form. <br /> <br /> Siteevahmtions. mpti¢.ale,trical, plumbingandm,cha,idalworkreqoims,patatep,n, ni,. Check wlth Marlon C0/mty ,utldlng Inspeetl0n b¢£~/~,bml/ttmg thllapplida <br />lvlC 15-73 Rev, 11/91 <br /> <br /> <br />