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Received By:,~,~-~ <br />Zoniqg Validation: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1..lob Description <br /> <br />MARION COUNTY BUILDING INSPECTION ~ USE ONLY <br />220 High Street NE [ City Setback Req~ficements: <br /> Salem, OR97301 l~,,,t~ ...~,~ I'""' r <br /> 8 00am 4 3 l I hon¢ 588 ' ' · , " <br /> C$~-A-15on*~88-790{~J ~ I ..... ~[JJ t ~ ~ .... / <br /> <br /> BUiLO~G PERM~ APP~AT~ 6 ~9~ <br /> <br />RESIDENTIAL <br />( ) Addition ( )R¢loeatio~ <br />( ) Alteraton ( )Demolition <br />( [~'~Accessory ( ) OIhct <br /> <br />Trus,s( ) or P. aftcr( ) [ No. Stodes <br /> <br />COMMERCIAL <br /> ) Addition <br /> <br /> ) Alteration <br /> <br /> ) Change of Occupitncy <br /> <br />( ) Sign <br /> <br />( )Demolition <br /> <br />( )Other <br /> <br />Load or Number of Employees <br /> <br />l-leigbn // / <br /> <br />2. Lncafion of Installation <br /> <br /> fie, 0 q No., .................. <br />Subdivision L~ ghmk <br /> <br />"~;~tion R~ TownsMp ~S Range ~ ~ Zme ffM Map Water Su~ly: <br /> <br />3. Contractor Information <br /> <br />~f~himsubc~ntmc~rs~wi~h~m~n~ysubc~ntract~rsreg~steredwiththeC~nstruction~ontract~rsB~ard iflcbangcmymilldar/ddoh[l'cagct~cralcontraetor ]w'illcxmtract <br />with a contractor who is registered withe Construction Contractor's Board, and will immediately notify Marion County cq' thc ilanle of the coaltaetot'. <br /> <br /> ( ~lm a registered bu~der OR :he au~orized m~osentadve of a registered bt~ldcr. ~.~ 3 at 116 ~r~ <br /> <br />Architect name:/t~/~/j g I Mailing Address: ,I Phone; <br />4. Fee Schedule <br /> <br />A. VALUATION(See "Valuatloa Schedule" <br /> <br /> square footage.) <br /> <br /> (I) Permit Fee <br /> <br /> (2) 5% State Surcharge (,05 x Al) <br /> <br /> (3) Structural Plan Review (,65% x Al) <br /> <br /> (4) lrim/~ Safmy Plan I(evicw (,4(1% x Al) <br /> (5) qx.m~g-~-.=~ e, if applicable (.05% x A 1) <br /> <br />B. Miscellaneou~ Fees <br /> <br /> (1) Driveway w/curb (¢ $7,50 <br /> <br /> (2) l)dvcway w/o curb ~o~ $ FL(X) <br /> <br /> (3) Site Plan Review (commercial only) (~j3 $79,(×) <br /> (4) Additional I Jail Reviews or Addendmns <br /> (5) /nvesttgation Fee <br /> <br /> (6) Re .spectlon k:eQ) $2f00 <br /> <br /> ('7) Other h~spectlons not listed above <br /> <br /> hereby certify that the above information is correct and that I have read and understand the [nfomlation Notice Lo Properly Owners about Constmctiou I/esponsthilities on the <br /> <br />SignatureofApplicant: L/~Wi~~ l)a~e: ~-3 q~ <br /> <br /> Site evaluatkm~, ~eptie, elear~(Mn~j~ovk ~Bquite ~e~eate peri. its. Check w{th Marion County I~uilding Inspect/on Imfore %thmithng ~is <br /> application. <br /> <br />MC 15-73 Rev, 11/91 <br /> <br /> <br />