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FOR~ALIDATION] MARION COUNTY BUILDING INSPECTION <br />I - '7 ...... /~' -- f A [ ,, COMMUNIT~.Y_.DEVELOPMENT CENTER <br />IReee, jved By: ~~AI It.e- 285 church St. NE - Room 132 [City Setback <br />I / ~ , ~, ...... ¶ __--m~l~ Ir~/Salem, Oregon 97301 ~ <br />[Zonin~Validation: ~/ ~{~.,~,,a.m(S:a0pmP~oneSSS-$~..oa .~/a .,O <br />L ~ J ~ ._..,, FAX ~88-7948 I <br /> ~ ~/B~JI~)~aNG PERMIT APPLICATION <br /> <br /> ( ) A~tion ( ) Rel~aaon I ( ) A~tion ( ) New / ~ <br /> ~scfip~f ~k ~ ~ Is ~ a hiswfic~ bu~d~g? <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />L <br /> <br /> ~ Water Supply: <br /> Private Well ( ) <br />Acres In~g. Lot Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> ) <br /> <br /> ) <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the prope~y owner or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (Se~ "Valuation Scheduie" to d~tmraine valuation bared <br /> <br />on squ~re foo~ase of project.) <br /> <br />( 1 ) Permit <br /> <br />(2) 5% State Su..~harge (.05 x Al) <br /> <br />(3) Swactural Plan Review (.65% x Al) <br /> <br />(4) Plm & Life S ~a!~e~'/plan Review (.40% x Al) <br />(5) ~(.~5% x AD <br />(6) Seismic Surcharge <br /> <br />B. Miseell~us Fees <br /> (1) Additional Plan l~views or Addenduma <br /> <br /> (2) Investigation Fee <br /> <br /> (3) R~inspection Fee {~ $25.00 <br /> <br /> (4) Other Inspextlons not listed above <br /> <br />TOTAL <br /> <br />=$ <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 /> <br />Nam~ o f Applicant <Plcas~ Prim · 4~{~ "~ ~/{~Z~ .Phone: <br /> <br />Signature of Applicant: ~ _Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />