Laserfiche WebLink
FOR CITY VALIDATION <br />Received By: ' __ <br />Zoning Validation: <br />Date: <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNYI~Y DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> nTITT r~T~'~'~ D~T~MTT A I~l~I T~ATT~ <br /> <br /> FOR CITY USE ONLY <br /> <br />,City Setback Requirements: <br />Front: Rear: <br /> <br />Left Side: [ ,Right Side: <br /> <br />I RESIDENTIAL COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> ( ) Alteration ~K') Other ( ) Alteration <br /> ()Accessory (<e.p[ato.~e~t'l"" ( ) Change of Occupancy <br /> <br /> I No. of Employees: Existing - <br />Energy Path: E{~' No. Stories '] ZJ ' <br /> <br />Square F°°tage 'Basement: I"ain~°°r: i'-7(,c',~ ISec°ud~°°r: <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br /> New - <br /> <br />Garage: <br /> <br />Use of Structure: <br /> <br />Is this a historical building? Yes ~o ' <br /> <br /> No. Bedrooms: 3 <br />J Other: J Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> Property Owner h/~.) CEii,~. , C.~'~ ~0b~/~OV~ <br /> <br /> Mobile Home P~k <br /> Section { Township Range <br /> ~t Wid~ [ ~t Dep~ Ac~s <br /> <br />JMailing Address <br /> <br />Comer <br /> <br />Phone No. (g:)7 ~ "5 ~SCt <br /> <br />Block <br /> <br />IZone <br />Irreg, Lot <br /> <br />ILot <br />Space # <br /> <br />Water Supply: <br />Private Well ( ) Spring ( ) <br />Community Well ( ) City ( ) <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general con,actor. I understand that I must register as a construction <br />contractor if the stmctam is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br />I am a CONTRACTOR registered with the State of Oregon. <br />Business N~me <br /> (!0 4'~O. L J~ 0 .~ ~¢~ ('~, Registration No. <br /> - .bone 1-'3i't i <br /> MailingAddress '"'~.C~'~ r ,' /:l uu I <br />I am an AtrrHORIZED REPRESENTATIVE of the owner or contracto[ ~ t <br />property <br />· <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ <br />( 1 ) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Stmctaral Plan Review (.65% x Al) = <br />(4) Fire & Life Safety Plan Review (.40% x Al) = <br />(5) Zoning Surcharge, if applicable (.05/% x Al) = <br />(6) Seismic Surcharge = <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />RECEIPT: <br /> <br />=$ <br /> <br />TOTAL = $ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />Name of Applicant (Please Print,: ..~ _r) ~_ ~(_~ _.~ C h I~p J~O-~ J"k..,'~ Phone: <br />Signature of Applicant: <br /> Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />