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Reoalwd By:_ ~_ __Date: f'/~'~l COMMUNI~ DEVELOPIVfENT CElqTER <br /> ~Mg By: ~ ~ ~ City.. -~ ~ 3150 L~c~ ~. ~ - S~te C <br /> R~dpt ~:~ ~o~t:$ '~e ~ [ S~, ~cgon 97305 <br />......................... J~L~_~ ~ i~ I~~' 4:30 pm <br /> ~ ~ ~ ~ ~~on Line 373-442 <br /> <br /> A.[i%o <br /> JOB DE~ON MARI~N <br /> ~SmENT]AL . , BUILDING INSPEC ON <br /> ( ) New ~ Ac¢essou ( ) ~d~dum ( <br /> ( ) ~on {) Reioc~on( ) ~¢r ( )AEemtion ( )Addendm <br /> ( ) ~difion ( )Addi~on ( )Si~ <br /> ( ) <br /> <br />FOR CITY USE ONLY <br />City Setb~,cks: <br />Front:~ t Rear: ~ / <br />Left: D 7 Right: Q .w <br />Special: <br /> <br />( ) Change of Occup$ncy or Use <br />( ) ManufaCaned Dwelling Park <br />( ) Recreational Vehicle Park <br /> <br /> Squar~ Footage: B~sement: 1st Floor: 2nd Floor: Other: No. Stories: t~ Un~: / Height: ~ ! <br />Number of Employees: S~ating Capacity: Numb¢r of B~dtooms: Existing: Proposed: <br />2. LOCATION OF INSTALLATION <br /> <br />CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />1 am the PROPERTY OWNER and own, reside in, or will reside in the completed stn~cture and will be my own general commctor. I undersland that I must <br />register ~s a construction contractor fi`the structure is sold or oflh'ed for sale before or upon completion, ff I him subcontractors, I will hire only suboontragtors <br />r~gister~d with the Construction Contnmtors Board. ff I change my mind and do him a general contractor who is registered with the Construction Contractors <br />Board, I will immediately notify Marion County of the name of the contractor. <br /> <br />( ) I am the AUTHORIZED REPRESENTATIVE of the prol~rty owner or the contractor. <br /> Bosin=ss Name (please print) <br /> <br /> Mailing Address: <br /> street City: Zip: Phoue: <br /> <br />( ) I am a CONTRACTOR registered with the State of Oregon. <br /> B~iness Name (please print): <br /> <br />Mailing <br />Addr~s: <br /> <br />Registration #: <br /> <br /> Street City: Zip: Phone: Fax: <br />4. FEES <br /> <br />~ VALUAIION ( See Valmtion Schedule to determine the xaluatinn <br />based on squai'e' footage of the project_) $ ~OJ, oCO O <br /> <br /> (I) Permit Fec 7 ,~.9o~e, c.~ O <br /> (:2) State Surcharge ~ × ^]) <br /> <br /> (4) Fire and IAfe Safety Plan Review (40% × Al) <br /> <br /> (6) Seismic Su~cl~rge~ if applicable (1% × ^l ) <br /> <br />~B. <br /> Miscellaneous Fees <br /> <br />(1) Addi Plan Review / AddendmnMhfimum one-haft hour @ $50/hr, <br /> <br />(2) Reinepecfion Fee ~ $50/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) Additional Sets of Plans ~ $10 per set <br /> TOTAL <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance or it'work <br />suspended for 180 days. <br />NamcofApplicant[PleasePrint]: ~'~-E~::~-'~ L. ~tt 7~/'/'- <br /> <br />~ilone: ~SZ~ ~/~4~ n -L:2Ja , ' - <br />Signature of Applicant: {J12,,~/~ ~_5. ~ - _..fi~La.~. Date: <br /> ]5-7 Revg,9, 6r L/0 f' - - - <br /> <br /> <br />