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FOR <br />.a~eiv~ <br />ZoningVali_dation;~ ,, ,o~, I <br /> <br />MARION COUNTY BUILDING iNSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 ' <br /> <br /> 8:00am. 4:300m Phone 588-5147 <br /> Code. A.Phon~ 588-7904 <br /> FAX 588-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Job Description <br /> <br />RESIDENTIAL <br /> ( ) Addition <br /> <br /> ( ) Aimrafion <br /> <br /> ( ) AecessoW <br /> <br />[FOR OFFICE USE ONLY <br /> <br />Square Feet: <br /> <br />City Setback Requlmments: <br /> <br />Front: ~ Rear: ~ ~' <br /> side:_..<--/ si. , <br /> <br /> ( ) Relocation ( },~Addilion ( ) Sign " <br /> ( )Other ( )c~..g~ofo~c.~n~y ( )Oth~r Bllll011~Id~ Y~ <br /> <br />Or ~fter ( ) I No, St0~e~ / [ ~,t L~d or N~bzr of F~ploy~es No, Bedroms: <br /> <br />2. Location of Installation <br /> <br />Subdivision ~t Bilk <br />Mobfl~ Home Pa~ ~ S~ce ~ <br />I,ot Wid,~'¢, 73" Lot D,~h ~, ........... Acres I~eg. ~[ ~ Come:_....~) CommunityPfivateWellwall (( )) Sptin, ( )City <br /> <br />3. Contractor Information <br /> <br /> ~, I own, reside ~, ~ w~ mhde ~ tho ~mplet~d stm~u~ <br /> <br /> ~^RION GOUN[Y <br /> <br />Contractor Businezz name & #,. ,,1 Mail~g Address; { Phon~; <br /> ( ) I am a regjs~d baflder OR ~c au~ofi~ mpresen~tiv~ of a ~gistemd b~en <br />Arch'metname'~' ~ ~""~ 'k ' "'Ma~gAddmss: ~q~/~ ~ /~ x[Phonc' <br /> <br />4. Fee Schedule '' : ~r~/a.~. ~'Z. '~ ~z~ 7 / <br /> <br />A, VALUATION (See "Valuation Schedule" <br /> to detemfine valuation I~sed on <br /> square <br /> <br /> (1) Permit Fee <br /> <br /> (2) 5% State Surcharge (,05 x Al) <br /> <br /> (g) Structural Plan Review (,65% x Al) <br /> <br /> (4) Fire & life Safety Plan Review 640% x Al) <br /> <br /> "',B, :Miscellaneous Fees <br /> <br /> (1) Driveway w/curb@ $7.50 <br /> Valuation: $.~, I~ (2) Driveway w/o curb @ $17,00 <br /> Iq3.~o .... <br /> (3) Site Plhn ReGew (commemlal only) (~ 879.00 <br /> ~ ~ (4) Additional Pla,I Reviews or Addendums <br /> <br /> (6) Reinspection Fee @ 525.00 <br /> <br />I hereby c~rtify-lhat the above infonnation is correct =d [hail have r~ad alia undef~tand the Information Notice to Propet'cy Owners about C <br />reverse side of this form, <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />