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FOR OFFICE USE ONLy <br />Re~eivtxl By: -- <br />Zoning Validation: <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High S~reet NE <br /> Salem, OR 97301 <br /> <br /> g:00am - 4:301~m Phone 588-5147 <br /> Co~e.A.Phone 588-7904 <br /> FAX 588.7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 TI-~ROUGH 4 <br /> <br />~NLY <br />[ City ~tback Requlrernfflt.~: <br /> <br />1. Job Description <br /> <br />( )Addition ( )gd~fion ( )AOdi~m ( )Sign ~. ~ ff~-~ <br />( )Acces~ ( )~er ( )~ofOcon~cy ( )O~cr <br /> <br />2. Location of Installation <br /> <br />$u~visi~ ...... L~ BI~ ........ <br />Mob~e Home Pa~ S~ ~ <br /> <br />Scion .... To~s~p ~ge ~e Map Wa~r Supply: ..... <br /> PfivateWell ( ) Spring ( ) <br />'~ot~fl~ '~'~pth A~s ~eg.~t Comer C~mmunit)'We~( ,,~, ,,City ( ) <br /> <br />3. Contractor Information <br /> <br /> ) 1~ own. reside in, or will reside in ~he completed structure. <br /> <br /> ) I undctstend Ihat I must mglstet a~ a eomtmeticra contractor ff the structure is soM or off¢1~1 for sale before or 0pon ¢ ,c~npletio~. <br /> ) I will be my own general eonttaetor. <br /> <br />( ) I am a ~'egi~ered b~kler OR lhe au~horlz~d representative of a ~gis'~rcd <br /> <br />4. Fee Schedule <br /> <br />A, VALUATION (See "Valuation Sehedale" <br /> <br /> square footage.) Valaafion: $_~ <br /> (1) Permit Fee <br /> (2) 5% State Surcharge (.05 x Al) <br /> (3) Smlemral Flan Revlew (,6~% x A 1) <br /> (4) Fire & Life Safety Plan R0vlew (.40% x Al) <br /> <br />(1) Ddveway w/mrb @ $7.50 <br /> <br />(2) Driveway w/o curb @ $17.00 <br /> <br />(3) Site Phn Review (eommcrciaI Only) @ $79,00 <br /> <br />(4) AddltionaI Plan Reviews or Addendums <br /> <br />(5) Investigation Fee <br /> <br />(6) Reinspection Fee @ $25.00 <br /> <br /> (5) Zoning Surcharge, if applieabl¢(,0$%×Al) = (7) Othe~ns~ionznot,%te~l abow~} -[ I ~ ~ ' <br /> <br />reverse ~ide of ~is form. ~ [ <br />NameoCApp{icant(PleasePfim): ~'~:~ ~~ ' Phone: <br />Signature of Applicant: Date: <br /> <br />Sit avakmfions, se *tie, electrical, plumbing and mechanical wo& mq~m seattle pemiu. Check wi~ Marion Co0ngy g~lding Inspection ~i'otc ~ubmitting this application. <br />MC 15-73 Rev, 1I~)1 <br /> <br /> <br />