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MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMEHT CENTER <br /> <br />FOR CITY USE ONLY <br /> <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br /> 8:00 am - 4:30 pm <br />24 hr. ~tion Line 373~427 <br /> FAX 588-7948 <br /> <br />iCity Setbacks: <br /> Froni:~l~ar: ~ / <br /> L~t~: ~ ~ight: ~ / <br /> Special: <br /> <br />1. JOB DESCRHrrION ^m x~'~ <br /> <br /> ( ) Ai~tation 0~'' ( ) Relooalinn <br /> ( ) Addition <br /> <br />BUILDING PERMIT APPLICATION <br /> <br />Subdivision: [ Lot: Block <br />( ) Mobile Home Park ( ) Mobile Home Subdivision Space #: Total t gpaces: <br /> <br />L CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOIN~ THE WORK <br /> <br /> ( ) I ~wa the PROPERTY OWNER and own, reside in, or wiU reside in the completed ~u~mx~ and will be my own general conlractor. I ~d tl~ I must <br /> register a~ a construction contrac~r iflbe structure is sold or off, red for sale before or upon completion. If I hire subcont~.~ors, I will hir~ only sul~ontrac~rs <br /> registered with the Conslmclion Contractoes Boar& If I change my mind znd do hir~ a g~neral conlractor who is r~gistered with the Constm~io~ Contrac~rs <br /> Board, I wLll immediately notify Marion County oftbe name of the contractor. <br /> <br /> () I am the AUTHORIZFA) REPRF~SENTATIVE of the property owner or lke contractor. <br /> B~in~s Name (please pr~m) <br /> <br />Mailing Address: <br /> City: Zip: Phone: <br /> <br />4. FEES <br /> <br />I am a CONTRACTOR mgizter~lb the Stal~ of O~gon. <br /> <br /> ~,~ ~ s ~ ' C~: ~ Zip: <br /> <br /> 7qq 11.7 <br />Phone: ~X: <br /> <br />A. VALUATION (Se~ Valuation Schedui¢ to determine the valuation <br />based on. squure footage of the projest) ~'$ ..,/~ ~., <br /> <br /> (1) P~mit Fee .,o~. ..~ <br /> (2) State Surcharge (5% x Al ) ~,i~i~. ,ff~-~ <br /> (3) Slxuctural Plan Review (65% x Al) <br /> (4) Fire and Life Safety Plan Review (40% x A.11 · ~ <br /> <br /> (6) Seismic Surcharge, if applicable (1% x Al) <br /> <br />B. Miscellaneous Fees <br /> <br />( 1 ) Addl Plan Review / Addendum @ $50/hr, <br />Minimum one-half hour $ <br />(2) Rcinspcction Fee @ S50/per inspection $ <br />(3) Investigation Fee $ <br />(4) Inspections outside normal business <br />Hours ~ $50/hr, minimum two hours $ <br />(5) Inspections for which no fee is specifically <br /> Indicated ~ $50/hr, minimum one hour <br />(6) Additio .nal S.as of Plans ~ $10 per set $ <br /> <br />I hereby ccatify that the above information is correct. Permits are non-transferrable'ahd cxpffe if work is not started within 180 days of issmmce or if work <br />suspended for 180 days. ~ <br />Name ofApplicant [Please Print]: [0~ 5/G tn~l~ ,, <br /> Mailing Address: ~o lOqff- <br /> Pho%~ 7tl~ 117 -~ <br />Signatare of Applicam: .~, ~'~/~ ~~ Date: <br />MC 1~-73 l~v 9/98 '* <br /> <br /> <br />