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FOR CITY VALIDATION <br />Received By: __ <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church SL NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am.4:30pm Phone $88-5147 <br /> 24 hr. Insl~CflOn Line S88.7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, ! THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> FOR CITY USE ONLY <br /> <br />I::- :;-: <br /> <br /> IEESIDENTIAL COMMERCIAL Use of Structure: <br /> <br /> ddifion ( ) Relocation ( ) Addition ( )New ~.~ t <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> ( )Accessory ( )ChangeofOccupancy ( )Other <br />Energy Path:I [ No.S,otSes ~ [ No. of Emphiyees: I~xlsmig - N~'~'- [ No. Bedrooms: ~H <br />S~qua~ Footage-Basement,. I Maln moor: I Second Floor: ] Garage: I Other: eight: <br /> <br />: n2ATION OF INSTALLATION ' tShn It{OO -') fhe. qx) .+. (or40 <br /> <br />Subdivision ~ Block <br />Mobile Home Park Spocc # <br />Section Township Raage Zone Map Wa~t Supply: N.~ <br /> PdvateWall~ Spring ( ) <br />Lot Withh Lot Depth Acres Irreg. Lot Corner Community Well City ( ) <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br />,,,~ 1 am the P.R_OPERTY O .WN~. R and own, reside in, or wi[l reside in th~ completmi s~ructute and will be my own g~n~ral contractor. 1 undemtand that I must register as a ~lxu~ou <br /> conh'actor ~f the structure ~s sold or offered for sale before or upon completion. If I hire sal~omractors, I will him only subconh-actors registered with th~ Construction Contractors Boa-d. <br /> If I change my mind and do hire a general conh-actor who is registered with the Construction Contractors Board, 1 will hnn~diamiy notify Marion County of the name of the contractor. <br /> <br /> ( ) I am a CONTRACTOR registered with the State of Oregon. <br /> Business Name Registration No. <br /> <br /> Mailing Address Phone <br /> <br /> ( ) I am an AUTHORIZED REPRESENTATIVE of thc property owner or contxactor. <br /> Noxn¢ <br /> <br /> Mallthg Address PhOlm <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of pmject.) <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Safal~ Plan R~view (.40% x Al) <br />(5) Zoning Surcha~ge, if applicable (.05% x Al) <br />(6) Seismic Sureharge <br /> <br />=$ <br /> <br />TOTAL = $ <br /> <br />I hereby certify that the above information is correct. <br />Pemaits are non-transferrable and expire if work is not star~ed within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Print): Phone: <br />Sign,t~e of Applicant: ,'~ ~ <br />MC 15-73 Rev 1/95 <br /> <br /> <br />