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[Foao.Ty VXcmA ON <br />ReceiVed By." _~_~ <br />Zoning Vanda~ion: ! <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> ( ) Addition ( ) Relocation <br /> ( ) All. ration ( ) Other <br /> (~ccessory <br />Dea~iption of Work ~~.~ ff <br />~ Pm: ] I~o. Storie~ <br />,~luarc Fontagc -Basement: [ Main Floor:. <br /> I <br /> <br />MARION COUNTY BUILDING INSPECTION i FOR CITY USE ONLY I <br /> COMMUNITY DEVELOPMENT CENTER <br /> I <br /> 285 Church St. NE - Room 132 ]City Setbeck Requirements: <br /> Salem, Oregon 97301 <br /> 8:00am-4: <br /> <br /> APPLICATION <br /> BUILDING PE~I~ <br /> MAY 1 ? 199~ <br /> <br />NIABION GOUNTY <br /> <br />- No <br /> <br />HeiSt: ,/.2.. ' <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring <br />Comm~ty wen ( ) City <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) I am the PROPERTY OWN'~R and own, mide in, or will reside in the completed structure and will be my own general contractor. I understand that I must register as a constmcfon <br />contractor if the slmcl~e is sold or offered for sale before or upon completion, ff I ~ subcontractors, I will Lire only subcontxacto~ registerod with the Construction Contractors Board. <br />ff I chn~ge my _mind and do hire a general contractor who is registered with the Construction Contractors Bo~xl, I will immediately notify Marion Connty of the na~e of the coutrnctor. <br />('~ I :ma a CONTRACTOR registered with th~ Slate of Or~gon. <br /> l~.us-iness m~e ~ .~ / l~egistration ~o. <br /> <br />(.~ ~ am an AUTHORIZED RI~^TIYE of tbe pmpe.y owner or contractor. <br /> <br />4. FEE SC~D~E <br /> <br />VALUATION (~ "Valuation Schedule" to d~t~-min~ valuation based <br />on square footage of project.) Valuatio~ $ ~ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surclm~ (.05 x Al) <br /> <br />(3) S~uctural Plan Review (.65% x Al) <br /> <br />(s) zonh~ s,,rcam,z~, if,mpUc, ble (.0S% x AD <br /> <br />(6) Seismic Surcharge <br /> <br />= ~. q3 <br />= ~.~ <br /> <br />B. Misc~llaaeons Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspecfion l~e ~ $25.00 <br /> <br /> (4) Other Insl:oztions not listed above <br /> <br />=$ <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not statXed within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Signature of Applicant: ,e ~ ,-.- Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />