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FOR CITY VALIDATION I MARION COUNTY BUILDING INSPECTION I FOR CrI'Y USE ONLY <br /> ~ "~- . ',~'~ ~" ' [ ) COMMUNITY DEVELOPMENT CENTF~ ~ ' <br /> <br /> Salem, tJrcgon v <br /> <br /> Btat,I)l G C0UN <br />CO~ ~ S~ONS, 1 ~OUGH 4 <br />~. JO~ DmC~ON ~ ~ _~ ~ BUlLBING INSPECTION <br /> <br /> ~~ CO~C~ [ U~ of <br /> <br /> ( ) A~fion ( ) Rel~on ( ) Aa~fion ( ) New I ~ O ~ <br /> ( ) ~mmfion ( ) ~r ( ) ~temfion ( ) Si~ { ~ ~ <br /> ( ~~ ( ) ~ge of ~cup~cy ( ) ~er <br /> <br /> _ <br /> <br />2. LOCATION OF INSTALLATION ~)0 ~.~.~, ~/ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) I am lhe PROPI~RTY OWNF.~ and own, re~dde in, or will reside in the completed structu~ and will be my own general contractor. I unde~tand that I must r~gist~r as a construction <br />contractor if the slmctu~ is sold or offered for sale before or upon completion, ff I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a geaead coolractor who is m~i~red wifh ~he Consmmtion Contractors Board, I will immediately notify Marion County of the name of the coflWactor. <br />(y)'""'/I am a CONTRACTOR registered wid~ t~e State of Oregon. <br />() I = an AUTHO~ '3';RI3/REPRI~F-,NTATIVE of tl~ property owner or con~or· <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> =$ <br /> <br />VALUATION (See "Vsluatio~ Schedule" to deter'mine valunlion based / <br /> <br />on KlUare footage of project.) Valualion: $ ~__~_' ~ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% Slate Sumharge ~.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br /> <br />(6) Seismic $oreharge <br /> <br />B. Miscenaneo~ ~ <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br />RF, CEiPT: (4)Oth~Ins~ no~ listed above <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started wiflfin 180 days of issuance or if work is suspended for 180 days. <br /> <br /> ,d ' <br />Signature of Applicant: / ~ ~. ~ ,.~//ir..,,) ~' -w ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />