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FOR OFFi~'USE ONLY1, MARION COUNTY BUILDING INSPECTION <br />R=eiv~ By' [½~- O. ~-,.,,~,3~Zo)220 ~i~ S~ ~ <br /> s~om, OR 97301 <br /> <br /> Code-A-One 588-7904 <br /> FAX 588-79~8 <br /> BUDDING PERM~ APPLICATION <br />CO~LE~ ~L SECTIONS, I THROUGH 4 <br /> <br />L Job Description <br /> <br />,,[pR OFFICE USE ONLY <br />City Setback Requirements,. <br />Fvonti o~ /~/~r: tS~ / <br /> <br /> ([?f Addition ()Re, location ()Addition ()Sign <br /> <br /> ) AItcrafton ( ) Demolition ( ) Alteration ( ) Demolition <br /> )Accessory ( )Other ( ) Chango of Occupancy ( )Other <br /> <br />'l'ross(L~ or Rafter( ) I No. sm~? o,~ .OccupantL~adotN0,m.~erofgmplo2mes <br />Squa~ F~/: Basement: I Main Flo~r: ~gSIO ,,[.,$,econd Floor; ~ [ Other: ....... Height; <br /> <br />Location of Installation <br /> <br />Subdividon Lot g I~k <br />Mo~e Home Park Space <br />Section <br />Lot Wid~ <br /> .,, <br /> <br />3. Contractor Information <br />Vro~y Ow~?~,, '7"a ~ '~6a H~ <br /> <br />( ) I ow-n, reside in, or will t~sidc in thc completed <br /> <br />4. Fee Schedule <br /> <br />[Phone: <br /> <br />to determine valuation based on <br /> <br />square footage,) <br /> <br />(l) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />O) Structural Plan Review (.(*5% x Al) <br />(4) ~!.40% x Al) <br />(5)' . , , , ' <br /> <br /> (l) Driveway w/curb@ $7,50 = __ ..... <br />Valuagon $ 5r~ gTegO (2) Driveway w/o curb ~ $17.~ = ~ .... <br />~'~ (3) Site Plan Re~ew (co ems my)(~$79 X = ~ <br /> /Z <br /> '~ (4) Addifiooal Plan Reviews or Adde*~duxns <br /> <br /> (6) Rdns~cti~ Fee (~ $25 00 <br /> (7) Other filS~cliona not listed above <br /> <br /> RECEIfff': <br /> <br /> hereby 5¢rlif~ ~at the above information is correct and ~at I have read and undcm~nd ~¢ ~foma i~ Not ce o :coporty Owners about Construcfiou Responslbilities <br /> <br />MC 15-73 Rgv. 11/91 <br /> <br /> <br />