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IFOR OFFICE USE ONLY <br /> <br /> Zeroing Va[idatipn: ~ <br /> <br /> COMPLETE ALL SECTIONS, 1 THROUGF( 4 <br /> 1. Job Description <br /> <br />MARION COUNTY BUILDING iNSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 ~ .~., <br /> <br /> FAX 588-7948 U ~. <br /> BUILDING PERMIT APPLICATI~; !it ~. <br /> <br />FOR OFFICE USE ONLY <br /> <br />C"[ty Setback Requjmnlents: <br /> <br />RESIDE L / COMMERCIAl. <br /> (~A~n ()Relocation ()Addition <br /> ( ) Alteration ( )Demolition / ( )Alteration <br /> ( ) Accessory ( )Other ( )ChangeofOccupaney <br /> <br />Tress ( <br /> <br />) New <br /> <br />) Sign <br /> <br />) Demolition <br /> <br />) Other <br /> <br />Use of SLmoture: <br /> <br />or Ral'tgr (~ ' [ No. Stories [ O¢¢tlpant Load or Number of Employees <br /> <br />2. L0eation oflnstallation ~-JFTV,"~- ~ ,~"-?~e~J~ <br /> <br />,robAddresa '~52~C)~~1~- '~[ffJ~ , TaxAcct'N°'~/~5~..} ~3-'t~)O CrossStme, <br />Mobile ~ome Park ~ ~& ~ S~c~ <br /> <br />Sec0ml [ .... ~,bwnskip t, ~ ~ Range ff~ : Z~m ~% Map <br /> ....... I>rivateWell ( ) Spdng ( ) <br />Lot Widm [~, [g Lol Dept~, ¢9 Acres I~eg. I~t Comer <br /> <br />3. Contractor Information <br /> <br />( ~l-~wn. ms[dc itl. ~wfll reside in the completed smlcnum. <br />( t~,;-ndcrsemd tha~ r must register as a eonstr0¢tion cOntractor if thc stmctote is sold or offered for sale before ov upon c<mtpletion. <br />(~}"T(vill be my own gea~erel contractor, <br /> <br />Contractor Busthess nme & 4/: [ MMliBg Address: I Phone: <br /> ( ) I am a registered budder OR the authorized representative of a registered builder. <br /> <br />Amh{tect name: [ MaJl~g Address: [Phone: <br />4. Fee Schedule <br /> <br />A. VA1,UATION (See "Valuation Sched~de" <br /> to detar, l)jn¢ wduatlon based {m <br /> square fo01age,) <br /> (1) Permit Fee <br /> <br /> (2) 5% State Surcharge (~05 x Al) <br /> <br /> (3) Slructurat Plan Review (,65% x Al) <br /> <br /> (5) Z~::!xg~e-'-.'c'"~'ol~i~able (.05% x Al) <br /> <br />Valuation: $~1~. ~ <br /> I I 0 <br /> = <br /> <br />(1) Driveway w/curb (q3 $7,50 <br /> <br />(2) Driveway w/o cuvb (~. 5 7 00 <br /> <br />(3) Site Plan Review (clm/mer(:ial ~mly) (~ $ 79.l×1 <br /> <br />(5) Investigatloll Fee <br /> <br />(6) Reinspcction Fee (~ $25.00 <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />