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MARION COUNTY BUILDING INSPEC'rION <br />COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br /> J~ / Rear: / ~ / <br /> <br />I. JOBDESCRIPTION <br /> <br />BUILDING <br /> <br /> RESIDENTIAL <br /> ( ) New <br /> ( ) Alteration <br />=~Add~on <br /> <br />) Accessory ( ) Addendum <br />) Relocation ( ) Other <br /> <br />Number of Employees: ff Seataig Capaei~y:.~ <br /> <br />2. LOCATION OF INSTAH~&TION <br /> <br /> MARION COUNTY <br />co vjt[lJJ lNG INSPECTION <br />( )New ( ) Multi Family <br />( ) Alteration ( ) Addendum <br />( ) Addition ( ) Sign <br />( ) Other <br /> <br />( ) ~ge of Ocenpm~cy or U~e <br />( ) Manufactu~l Dwelling P&ric <br />( ) Recreational Vehicle Park <br /> <br />Other: No. Stories: units: Height: <br /> <br />Number of Bedrooms: Existing: Proposed: <br /> <br />~lobile Home Park () Mobile Home Subdivision Space #: / 7 Total ~ Spaces: <br /> <br /> ~V~c~:~ ~O~?~ff-V~- ~ ~ ~VO P~el ~:~3V~ ~ ~ clowner Supply:() ~v~ Well ()~ We~ (~ <br /> <br />LVCONTRACg[~OR INI -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I ara the PROPERTY OWNER and own, reside in, or will reside in the complea:d slrueture and will be my own general conlraetor. I tmdevatand that I must <br />regismr as a construction conmtctor it'the structure is sold or offered for sale before or upon completion. If I him subconh-actors, I will hire only subcontractors <br />registered with the Constm~on Contractors Board. If I change my mind and do hire a general contractor who is registered with th~ Constmation Contractors <br />Board, I will immediately notify Marion County of the name oftbe contractor. <br /> <br />() <br /> <br />I am the AUTHORIZED REPRESENTATIVE of rite property owner or ~ eo~traetor. <br />Business Name (please print)~ <br /> <br />Mailing Address: <br /> Street CRy: Zip: Phone: <br /> <br />() <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br />Business N~e (please print): <br /> <br />Mailing <br /> <br />Registr~tinn #: <br /> <br /> Street City: Zip: Phone: Fax: <br />4. FEES <br /> <br />A. VALUATION (Sec Valuation Schedule to determine the valuation <br />based on square footage of the project) $ <br /> <br /> ( 1 )Pennit Fee V '~- <br /> (2) State Surcharge ffa~'x Al) <br /> (3) Stn~:tural Plon Review (65% x Al) <br /> (4) Fire and Life Safety Plan Review (40% x A1 <br /> (5) Zoning Surcharge, if applicablo-(-6~4rx-~ <br /> (6) Seismic Surcharge, if applicable (]% x Alfl~ <br /> <br />B. Miseellauaous Fees <br /> <br />( 1 ) Addl Plan Review / Addendum @ $50/hr, <br /> Minimum one-baflf hour <br />(2) RCmSlX~tion Fee ~ $50~per inspection <br />(3) Investigation Fe~ <br />(4) Inspections outside normal business <br /> l~um ~ $50/bx, minimum two hours <br />(5) Inspections for which no fee is specifically <br /> Indicated (~ $50/hr, minimum one hour <br />(6) Additional Sets of Plans ~ $10 per set <br /> TOTAL <br /> <br />I hereby certify that the above information is correct. Permits are nga~Kansf~le and expire if wurk is not slatted witkin 180 days of issuance or if work <br />~ded for 180 days. ~ ~ [ ) ,. <br />NumcofApplicant [PleasePrint]:~K,O~'~i'L..~ (,~ ~ ~'~-4~ , _ <br /> MallingAddress:l~-.-~'z--;~2':)- [~l.O[~=)~t~l~--_x"~' ,~_ ~,~. MIJIY~flLL~ <br /> .gyne: "/.., - / 7J' ' ' ? d~-,? tO3 '~/-, / '/-" ' q "J:~'~-5 <br />SiguatureofApplican~__A_~__,,_?_,,~.~-.~"~f ,¥,~'~ ..... Date: '7.JA/F-t~' ' - <br /> <br /> <br />