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ceiy~d,B~y: ~ <br />I~oning Validation: <br />II'ate: - //- ? ? <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CEN'H~,t <br /> 285 Church St, NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:OOam-4:3Opm Phone <br /> ~4 hr. Inspection Line ~8.7904 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> FOR CITY USE ONLY <br /> <br />City ~k l~Uil~lm~t~: <br /> <br /> RESIDENTIAL COMMERCIAL 1~.6~' ~ i ~ ~ l <br /> (~ddition ( )Relocation ( )Addition ( )New 3 IO~ ,- , <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> ( ) Accessory ( ) Change of Occupancy ( ) Other <br /> <br />Encrgy Path: I No. Stories I No* of Employees: Existing- New- [ No. Beatrooma: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />S~fion ~ Township ff~ ~e ~ ~ ~e ~ Map ~ Wa~rSu~ly: <br />~twidm ~ ~t~m ~ Acm ~.~t ~ ~u~yWe~ ( ) ~ (~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> () <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the propeaXy owner or comractor, <br /> <br />4. FEE SCHEDULE <br /> <br />on sqtmr~ footage of project.) Valuation: <br /> <br />(2) 5% Stat~ Suzcharge (.05 x Al) <br /> <br />(3) Smlclxlrat Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Salty Plan Review (.40% x Al) <br /> <br /> (6) Seismic Surcharge = 7/. ~ <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not statt~l within 180 days of issuance or if work is suspend~l for 180 d~ys. <br /> <br />Signature of Applicant: ~ J <br /> <br />MC 15-73 Rev ltD5 <br /> <br /> <br />