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FOR OFFIC~ U~E O,)?Ly [.~ MARION COUNTY BUILDING iNSPECTION FOR O'PJPICE USE ONI~Y <br />Received ~y: {/z.i¢3. ~ Lff. z~ 220 High S~t <br />Zoning Vali~tion: ~ ff ~l Salem, OR ~301 <br /> <br /> BUdDiNG P~RM~ APP~TION <br />COMPLETE ~L SECTIONS, 1 T~OUGH 4 <br /> <br /> I. Job De~ription <br /> <br />2. Loeationoflnstallatlou ..~t~t~' 4 d.'//~-ff f~' ~ 7'3'''2-~ <br /> <br />3, Contractor Information <br />ProP~r~yOwner'"~ ~ ~ <br /> <br />Mailing Address [ Phone NO: <br /> <br />( ! ) I own, r~side in, cc will reside in thc ~mpleted structure. <br /> <br /> ( ~am a registered builder OR ~e su~o~d m~senmU3e of,a ~giste~d ~de~ ' 3, ~, .~/e~ j Or< qlge <br />' 4. Fee Schedule <br /> <br />A. VALUATION (See ""/alualion Schedule" <br /> to determlne valuation based on <br /> square fOOtage.) <br /> (1) permit Fee <br /> <br /> (2) 5% Stat~ Surcharge (,05 x Al) <br /> <br /> (3) Stnlctural Plan Review 665% x Al) <br /> <br />Valaarion: $_ ,~D O <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Driveway w/curb @ $7.50 <br /> <br /> (~) Driveway w/o curb @ $17.00 <br /> (3)t Sift'Platt Review (e~me~al <br /> (4) Addi~nal Plan Renews orAddend~s <br /> (5) ~sfigafi~ Fee <br /> <br /> (4) Fire A Life Safety Plum Revi¢w (.40% x Al) = (6) Re. inspection Fee @ $25.00 <br /> ,.~~^,) . -- ~,,,7~ (7) Other Inspections not lls~:d above <br /> <br />Ireh c?er er ~beY.~ :~; ,0ff~l~: tf toh~e ~, o ye irfformafiofl is correct an(l that, have read al~d understand file ,~ f0rnla,inn No~¢e tO ?rope~y Owner~ about Con~tmetJ0n Re,pon sibi~ ties on th, <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />