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MARION COUNTY BUILDING INSPECTION <br /> <br />I FOR CITY USE ONLY <br /> <br />P t: / /5- <br />Left Side: ~ Right Side: ~ <br /> <br />FOR CITY VALIDATION I <br />Receiv,,ed By: ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> S~ Oregon 97301 <br /> <br />BUILDING FEPs~IIT AP~ <br /> ?/'V (C II <br /> <br />COMMERCIAL '~'ld/j~i L'{Jl <br /> <br />1. JOB DESCRIPTION <br /> <br />( ) Addition ( ) Relocation ( ) Addition cw <br />( ~t. Alteration ()Other ~Alteration <br />( )Accessory ( )ChangeofOccupancy ( )Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLISASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am the PROPERTY OWNER ~nd own. re'dc in, or will reside in the completed structure and will b~ my own general contractor. I understand that I must register as a construction <br /> con~ractor if thc structure is sold or offered for sale before ur upon completion, ff I hire subcontractors, I will ~ only subcontngtors registered with thc Construction Conwactors Board. <br /> If I change my mind and do hire a genera! conm~ctor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of thc cona'actor. <br /> <br /> (~ I am a CONTRACTOR registered with the State o f Oregen. <br /> <br />4. FEE SCHEDULE <br /> <br />Au VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square foolage of project.) Valuation; $ <br />(1) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = ~' <br />(3) Structural Plan Review (.65% x Al) = Z- ~"~ <br />(4) Fire & Liin Safety Plan Review (.40% x A 1 ) = t~ ~' - q ~ <br /> 7. <br />(6) Seismic Surcharge = - O - <br /> <br />(2) Investigation Fee <br /> <br />(3) Ralnspeetion Fe~ @ $25.00 <br /> <br />(4) Other Inspections not listed aimvc <br /> <br />=$ <br /> <br />TOTA~ --~ <br /> <br />I hereby ce~ify that the above information is correct. <br /> <br />Signature of Applicam: ~ ('NL~\ ~,. Date: <br />MC 15-73 Rev 1~5 <br /> <br /> <br />