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CITY. VALIDATION] <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br />BUILDING <br /> <br />FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br /> <br />PAght Side: <br /> <br />1. JOB OESCRIFIION <br /> <br />( ) Addition ( ) Relocation ( ) Addition ( ) New <br />( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br />(~(Accessory ( )ChengeofOceupancy ( )Other <br /> <br />2. LOCATION OF INSTALLATION ,~. ~,. ~ z ? ~g' <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am the PROPERTY O~NER and own, reside ia, or will reside th thc completed struciure and will be my own general contractor. I understand that I must register as a constractJon <br /> <br /> I am a CONTRACTOR reglstsred with the Sta~e of Oregon. <br /> <br /> I am an AUTHORIZED REpR~ENTATIVE of the property owner or contxactor. <br /> <br />~o= ~tt3-1"71/ <br /> <br />MailJag Address ~ ~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedule" to de~ecmlne valuation bosed <br /> <br />on square footage of proj~t) <br /> <br />(1) Pennlt F~ <br /> <br />(2) 5% Stat~ Surcharg~ (.05 x Al) <br /> <br />O) Structural Plan R~vi~w (.65% x Al) <br />(4) Fire & Lifo Safely Plan Review (.40% x Al) <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br />(6) Seismic Surcharge <br /> <br />B. Miscellaneous Fees <br /> (1) Addillonat Plan Reviews or Addendt~ms <br /> (2) Investigation Fee <br /> (3) Relnspemion Fee ~ $25.00 <br /> (4) Other Inspections not listed abow <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire ff work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Signature of A pplican t :"-')~'r~'~':i~:~-'~"~~'~--) Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />t, <br /> <br /> <br />