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IF, OR CITY V~LIDA/dTION <br /> <br /> Date: ~/~-~ t//t)~' <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Roam 132 <br /> Salem, Oreg <br /> <br /> ~l hr. Inspection I~$0~V --i~.~ <br /> FAX <br /> BUILDING PERMIT APPd~T~/N 1996 <br /> MARION ¢0UNTY <br /> <br />]?OR CITY USE ONLY <br /> <br />1. JOB DESCRIPTION BUILDING INSPECTION ~ - f.~..~ <br /> <br /> RF~IDENTIAL COMMERCIAL Use of Structure: <br /> ( ) Addi,on ( ) Relocation (~-0~dd~tion ( ~'~ew /l/]nTert,I <br /> )Alteration ( )Other ( )Alteration ( )Sign /0~/~ BO/ <br /> ) Accessory ( ) Change of Occupancy ( <br /> ) Othe. r ~ . <br /> <br />Squar~ Footage -Basement: [ Main Floor: ~l~l~O ] Second Floor: ]Garage: ]Other: ]Height: <br /> <br />2. LOCATION OF INSTALLATION <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 s~ructure and will be my own general contractor. I understand that I must register as a construction <br /> <br />4. FEE SCHEDULE <br />I Ao i B, Miscellaneous Fees <br /> <br />VALUATION (See "Valuation Schedale" to determine valuation based <br />on square footage of project.) Valuation: $ ~l~ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% Stat~ Surcharg~ (.05 x Al) <br /> <br />O) Structural Plan R~v~ew (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(l) Additional Plan Re~iews or Addendums <br /> <br />(2) Investigation Fe~ <br /> <br />(3) ReinsgeOion Fee ~ $25.00 <br /> <br />(4) Oher Inspections not listed above <br /> <br />5/. <br /> <br />TOTAL <br /> <br />=$ <br /> <br />I h~,by certify that the above information is con~ct. <br />Peralits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Print): ~.~J..4<.~- /--~-~ /~ t't, ~-~t-t ~ r4. r., & Phone: <br /> <br />Signature of Applicant: ~ ~.~-~t J~-~&~'-~ Date: <br />MC 15-73 R~v 1/95 <br /> <br /> <br />