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J FOR CITY U$~ ONL~ O I Receipt#~ ~.~9~ Amount:$~s~. ', MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 3150 Lancaster Dr. NE - Suite C Salem, Oregon 97305 8:00 am. 4:30 pm FOR CITY USE ONLY City Setbacks: ~ Left: O' Right: O ' 1. JOB DESCRIFrlON RESIDENTIAL ( ) New ( ) Accesso~ 9~ Alteration ( ) l~e!ocatinn ( ) Addition 24 Im Inspection Line 373-4427 Special: FAX 588-7948 BUILDING PERMIT APPLICATION ~ , COMMERCIAL !( ) Addendum ( )New ( )MnltiFamily ) Addition' ( ) Sign ( ) Rzcrealional Vehicle Park l)escfiptionofWork: ~,'t~l'~q 3 $,'~$ O~ -./ Use of Structure: ~ O 0 Energy: NumberofEmployees: ~ Seating Capacity: NumberofBedrooms: Existing: ..~ Proposed: 2~ LOCATION OF INSTALLATION ( ) ~o~ile Bom~ ~R ( ) ~obile Bom~ SuMivblo~ gp~ ~: To~ ~ g~s: ~: ~ ~2S~D Zone: ~L P~calS~e: ~O ~/O0 () SF O AC UGB: ()Y () N ~o~ ~or: ~ } P~cel ~: W~ Supply: ( ) ~v~ WeR ( ) ~ WeR ~ _.rascal ~lOo 9~O ffoqoo c~ 3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK 1 am the PROPERTY OWNER a~d own, reside in, or will reside in the Completed structure and ~ be my own general contractor. I understand that I mu~t re gist~r as a construction contractor tithe slrucwre is mid or offered for sale befor~ or upon completion, ff I hire sub¢onWactors, I will hire only subcon~actors registered with the Construction Coatmctow Board. If I ch~mge my mind and do hire a general contractor who is registered with the Con.ruction Conlractors Board~ I will imnmdia~ly notify iv~rion County of~e nam~ of~e contractor. I mn the AUTHORIZED REPRESENTATIVE of the property owner or the contractor. Street City: Zip: ' ' ~'~*~ Phone: () · I am a CONTRACTOR registered with the State of Oregon. Business Name (please print): Registr~ion #: M~ling Addmss: S~et Ci~: Zip: Phone: F~: 4. FEES ': VALUATION (See Valuation Schedule to detemfine the valuation based on squsre footage of the project) $ ~1 75. O ~ (1) Permit Fee ~'~ (2) State Sureharge4r~x Al) (3) Structural Plan Review (650/0 x Al) (4) Fire and Life Safety Plan Review (~ x A1 ) ---- -- (5) Zoning Surcharge, if applicable (6% x Al) (6) Seismic Surcba~rge, if applicable (1% x Al) B. Miscellaneous Fees O) Addl Plan Review l Addendum ~ $50/hr, Minimum one-half hour $ (2) Reinspection Fee @ $50/per inspection $ (3) Investigation Fee (4) Inspections outside normal business Hours @ $50/hr, mirdtraum two bou~: $ (5) Inspections for wlfich no fee is specifically Indicated @ $50/hr, miuimum one hour (6) Additional Sets of Plans C~ $10 per set $ TOTAL $~-~'~, ~ I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not sterted within 180 days of issuance or if work saspanded for 180 days. Name of Applicant [Please Print]: Mailing Address: Pho~fl:. 7~t /Oq9 Signature of Applicant: ~-' MC 15-73 Rev 9/98 Date: