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FOR CITY. VALIDATION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY' DEVELOPMENT CENTER <br /> 285 Church St, NE - Room 132 <br /> Salem. Oregon 97301 ,..:i~'~~ <br /> 8:00am-4:3Opm Phone 588-5147 / <br /> 24 hr. Inspection Li~e 588-7904 <br /> <br />Fo__g CITY ] <br /> <br />1. JOB DESCRIPTION ~ ~ ~5 <br />luv, sm~t'rrlA[ COMM~iRCIA[MARION~ ;O[~l'l'Y uso ofstructum: <br /> <br /> ( )Addition ( )Relocation ( )Addi~lL{]l~{s iNSPE6fl0Iiw <br /> ( ) Alteration ( ) Other ( ) Alteration (X~ Sign <br /> ( )Accessory ( )ChangeofOccupancy ( )Other <br /> <br /> 9es;rlp~ionofWork 1.~)~,~'..t~770.,.J K~::,dflCt~ .~l~t-J~L.~.;'-- {!sthlsahistodcalbuildlng? Yes - <br /> Crier. Fath: I No. Stories I 1%. De £mployee,: £xistlng - l%w. <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION --PLEASE INDICATE WHO IS DOING TIlE WORK <br /> <br /> ptz:'-V/..:"~- ~l~'k,' ~'~.>. ¢-t~ <br /> <br />4, FEE SC~DULE <br /> <br />A, <br /> <br />VALUATION CSee "Valuation SchedUle" to determine valualion based <br />on square footage of project.) Valuation: S ~'ff <br /> <br />(I) permit Fee <br /> <br />(2) 5% Stat~ Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x A),) <br />(5) Zoning Surcharge, if applicable (.05% x A t) <br /> <br />(6) Seismic Surcharge <br /> <br />Miscellaneous F~s <br /> (I) Additional Plan P~ vi*ws or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspe¢fion Fee @ $25.00 <br /> <br /> {4) O~¢r Inspeefons not listed above <br /> <br />TOTAL <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not star,ed within 180 days of issuance or it' work is suspended for 180 days. <br /> <br />Name of Applicant (Please Print): phone: <br />Signature of Applicant: Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />