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1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br />( ) N~w () Accessory <br />( ) Alteration ( ) Relocation <br />( ) Addition <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOP~ <br /> 3~5o ~c~t~r yr. ~ <br /> Salem, Oregon 97~/ffJ~ <br /> 8:00 am ~ 4:30 Pd~'~ ~ C(-~.~ <br /> 24 hr. Inspection Line 373-~27 <br /> <br />Addendum ( )New ( <br />Other ( ) Ai~rati0n ( ) <br /> < )Ad~o~ ( isib~4/ <br /> (a~.Other <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br />Front: ~) Rear: fi->__ <br /> <br />Special: <br /> <br /> ( ) Change of Occupency or Use <br /> ( ) Mamffactured Dwellin§ Pa~k <br /> ( ) Recreational Vehicle Park <br /> <br />Square Footage: Basement: 1st Hoer: ~ 2nd Floor: I Other: No, Stories: <br /> <br />Number of Emp!oyees: Seating capae~: ! Numl~r of Bedrooms: Existing: <br /> <br />~ergy: <br /> <br />Units: Hoight: <br /> <br /> Fropo~ed; <br />2. LOCATION OF INSTALLATION <br /> <br /> · I <br />Subdivision: Lot: Block <br /> <br />( ) Mobile Home Pank ( ) Mobile Home Subdivision Space #: Total t/Spaces: <br />Map.~...~. ~l~gone: ~__.~., PaxealSizc: ()SF () AC UOB: ()Y () N <br /> Parcel#: I Wa~erSupply: ( ) Private Well ( ) Community Well <br /> <br />CONTRACTOR INFORMATION --- PLRASE INDICATE VOIO IS DOING THE WORK <br /> <br />( ) I ~m the PROPERTY OWNER and own, reside in, or will reside in the completed stm~mr~ ~nd witl be my own general contra~or. I understand that I must <br /> mgis~r as a consmmtion contractor if the structure is sold or offered for sale before or upon completion, ffl ~ subcontractors, I will hire only subcontractors <br /> <br /> Business Name (please print~ <br /> <br /> Street ' ' City? ' ~ Phon.: Fax: <br /> <br />4. FEES <br /> <br />A. VALUATION (See Valuation Schedule to detcrmfne the valuation <br />based on squure footage oftheproject) $ /.., ~,~ ~ <br /> <br />( 1 ) Permit Fee <br />(2) State Surcharge (5% x Al) <br />(3) Structural Plan Review (65% x Al) <br />(4) Fire and Life Safety Plan Review (40% x Al) <br />(5) Zoning Surcharge, if applicable (6% x Al) ~~..~ <br />(6) Seismic Surcharge, if applicable (1% x Al) <br /> <br />Miscellaneous Fees : <br /> <br />(1) Addl Plan Review / AddelmkUn @ $50/hr, <br />Minimmn one-half hour $ <br />(2) Reiuspection Fee @ $50/per inspection $ <br />(3) Investigation Fee $ <br />(4) Inspections outside normal business <br />Hours @ $50far, minimum two hours $ <br />(5) Inspections for which no fee is specifically <br />Indicated ~ $50/hr, rain/mum one hour <br />(6) Additional Sets of Plans @ $10 per set $ <br /> <br />f <br /> <br /> hereby certify Lhat the above information is correct, Permits are non-transferrable and. expir~, i~ork is not started within 180 days of issuance or if work <br />suspandedfurlS0days, r~ / ti I ~ [ J~ [~ . <br />Name of Applicant [Pleasc Print]: ! { ]CtC ~ 1~( [.,.DF?X ~ ~. ] Lle'l_A .~. ,[~/. ~d,~J <br /> M~ailing Address: <br /> <br /> .~hon~ <br />Si~atureofAppncant: !] ~i2.A3~~ , .~. Z~Z).- Dale: <br />MC15-73 Rev9/9fl <br /> <br /> <br />