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COMPLETE ALL SECTIONS. 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> <br /> 285 CharellSt. NE - Room 132 <br /> salem~ 0i~go n 97301 <br /> <br />BUILDING PEm~ $PPLIC~ ~1 <br /> / <br /> <br />I FOR CITY USE ONLY <br /> <br /> RESiDENTIAL COMMERCIAL ]/l/Sp~ t..¥ ! ~ Use of S~mcture; <br /> ~ ( )Relocation ( )Addition &'~'t~ <br /> ( )Alteration /gE~5~ ( )Altention ( )Sign <br /> ( ) Accesso~ OP~ D/~ ~ ~ ( ) Ch~ge of Occupancy ( ) Other <br /> <br />Energy Path: Fo. Stories l So. <br />Squ~eVoomge-B ....... t:~/~ ]Mainmoor: ~Z¢~Secondm .... ,~ [G~age: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />PropertyO .... ~-~ .~,~/t:~t~) ] Mailing Address ~oA q// ~o~No.$O3 85q-~7~1 <br /> <br />SuMivision ~ ~ ~ ~ ~ ~ ~ Lot ~ Blink <br /> () Spdng ((~ <br />~tWid~ LotDep~ Acres~ Img.~t ~O C~r ~O Co~unltyWelt ( ) <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ~/' I ~m the PROPERTY OWNER and own, reside in, or will reside in lhe completed structure and will be my own g~eral contractor. I understand that I must register as a construction <br /> <br /> contractor if the structure is sold or oft~red for sale before or upon completion. If I hire subcontractors. I will hire only subeontraetoi's registered with the Construction Contrac~n Board. <br /> If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board. I will immediately notify Marion County of the name of the con~raetor. <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 the property owner or contractor. <br /> Name <br /> <br /> Mailing Address Pbo~e <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on squ~e footage of project.) Valeafion: $ '~1. q <br /> <br />(2) s% st~t~ Su,:~rge (.os ~ <br /> <br />(3) Structural Plan Review (.65% x Al) <br />............................. <br />(5) ~ning Surch~ge. if applicable (.05% <br /> <br />(6) Seismic Surch~ge <br /> <br />B. Miscell~ngous Fees <br /> ( I ) Additional plan Reviews or Addendums <br /> (2} lnvestigalion Fee <br /> (3) Reinspection F~e @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br /> RECEWr: ~.w <br /> <br />=$ <br /> <br />TOTAL <br /> <br />I hereby certify that the above information is correct. <br />Penmits am non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Print): <br /> <br />Signature o f Applicant: ~..4~- <br />MC 15-73 Rev 1/95 <br /> <br />Phone: <br /> <br />Date: <br /> <br /> <br />