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CITY V~LiDA~ION' <br /> <br />Oregon 97301 <br /> <br /> I <br />( ) Addition ( ) Relocation I ( ) Addition <br />( ) Alteration ( ) O~her I ( ) Alteration <br />( ~,l~ccessory [ ( ) Change of Occupancy <br /> <br /> MARION COUNTY BUILDING INSPECTION { FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CF2qTER <br /> 285 Church St. NE - Room 132 ICity Sed~.k ~: <br /> <br /> 24 hr. ] [Left Side: I Right Side: <br /> BUILDING <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> MARION COUNTY <br />1. <br /> ,/oB <br /> DESCRIFrlON <br /> P.V~U~ENTIAL COMMERCIAL ~ ~'' ~ ~'"'" ........... 0~ of SUucture: <br /> <br />( ) New <br /> <br />( ) Sign <br /> <br /> Is this a historical Imilding7 Yes -~.~ <br />New - ] No. B~konms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />IMailing Address <br /> <br />Subdivision <br /> <br />~S <br /> <br />Block <br /> <br />W~let Supply: <br />Private Well ( ) Spring ( ) <br />Commmaty W~ ( ) City (-q"'-- <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 sUucture and will be my own general contractor. I understand that I must register as a construction <br />conUactor if the sm~cture is sold or offered for sale before or upon completion, ff I hire subcontractors, I will hire only subconWactors registered with the Construction Contractors Board. <br />Ill change my mind and do hire a general conmictor who is registered with the Construction Comractors Board, I will immediately notify Marion County of the name of the contractor. <br />(,-fi"' I am a CONTRACTOR registen~l with the State of Oregon. <br />Bnsine~s Nan~ Registration No. <br />(,,fi' I am an AUTHORIZED REPRESENTATIVE of the property owner or comractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedule" to de~ valuation based <br /> <br /> on ~q.~ footag~ of ~joct.) val.-,ion: $ <br /> ( 1 ) Permit Fee <br /> (2) 5% State Surcharge (,05 x Al) <br /> (3) Structural Plan Review (.65% x Al) <br /> <br /> ($) Zoning S~eber~, if applka~bl~ (.05% x Al) -- <br /> (6) Seismic Surcharge = <br /> <br />B. ~scon~neons Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-Uansfen'able and expire if work is no~ s~v~d within 180 days of issuance or if work is suspended for 180 days. <br /> <br /> ' <br />Name of Applicant (])lease ' 'Plil:J~~..,~ ~/'" Phone: <br /> /_ . ' <br />Signature of ^pplicant: / ~ Dat~: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />