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[FOR CITY ~TALIDATION <br /> <br /> Validatio_n:/~ <br />[Date: ~-O5- ~]f-, <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COIy~viUNIT,Y DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> g:00am-4:30pm Phone $88-5147 <br /> <br />BUILDING PERMIT <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />L JOB DESCRIPTION qb'c <br />RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> _~Q~) AccessorJ <br /> [~scrit~ion of Wor~k ~ ~ <br /> <br />FOR CITY USE ONLY <br /> <br />Right S d~: /O ! <br /> <br />anIAL <br /> <br /> ition <br /> <br /> ration <br /> <br /> ge of Occupancy <br /> <br />~N~NG NSPEC'FION <br /> ()Sign <br /> <br /> ( ) Other <br /> <br />New - <br /> <br />Is this a historical building? Yes <br /> No. Bedrooms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Block <br /> <br />Water Supply: <br />Prlval~ Well ( ) Spring <br />Community Well ( ) Ci[y <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am th~ PROPERTY OWNER and own, reside in, or will rcsid~ in the completed structure and will be my own genexal contractor. I understand that I must register as a construction <br /> <br />MallthgAdd:r~ss Phone -~ t~-'~7~_~ <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to ~ne valuation b~ed <br />on squ~e footage of project.) Valuation: $ JJ/~' <br /> <br />(1) Permis Fee <br /> <br />(2) 5% StYe Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(5) Zoning Surcharge, if applicable (.05% x A 1) <br /> <br />(6) Seismic Surcharge <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Invc~rigatlon Fee <br /> <br /> (3) Ralnsgecfion Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br />KECEIPT: ~ <br /> <br />=$ <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 Prin~ ~ ~J ~ ~ ~lPhone: <br />Signature of Applicant: / ' Date: ~ <br />MC 15-73 Rev 1195 ~ <br /> <br /> <br />