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I FOR OFEiCE.USE ONLY <br /> <br />IZoning Validation: ' ' "; ~ <br />[Date:.,..~!'7~/~L ~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:00am - 4:30pm Phone 588-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 58g-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />[OR OmCE O,SLY <br /> Setback Req~tirements '. <br /> <br />Front} Rear; <br /> <br />1. Job Description <br /> <br />RESIDEN'IIAI, '~OMM .ERCIAL ( )Ne~ lJse of Structure: <br />( )Addilion ( )Relocation ( )Addition ( )Sign <br /> <br /> ( ) AlP~'ration ( )Demolition ( )Alteration ( )Demolition~/ ~. <br /> ( )Accessory (~er ( )ChangeofOceupaney ( )Other <br /> <br />Tmss(~o¢ Rafter( ) I No, s=ri= [O~¢-upantLoaaorNumberofEmployee8 No, Lkdrooms; <br /> <br />Squ~re,,?e~t: ....... Basement: i o . I ........ I O,h,: ..... <br /> <br />2. Location <br /> <br />Mob~e llome Park Space ~ <br />Se~tlon ~ff.~ ~_~ lbwmhip ~ Range ~ Zone ~ Map Water Supply: <br /> .................... PrivateWel[ ( ) Spfir~g ( ) <br />l,otWid~ 't ~D ~ l.,otI)e~h ~ Acres I~eg.~t ~O Comer ~ (omm ~>'Ws~,( ) (;ity ~' <br /> <br /> Contractor Information <br /> <br />( ) Iown, msid¢in, oi'wilhcsldoJnthecompletedstruc~ure. ~l~$IJt[l~ 0 7.~-2~-- <br />( ) I understand that I mu~t rcgisIot as a construction contractor if the structure is sold or offered for sale before or upOn ¢ta~plction. <br /> <br />( ) I will be my own general conlra¢iot, <br /> <br />vqc/- /~¢? ........ <br /> <br />4. Fee Schedule <br />A. VALUATION (S~e "Valuation Schedule" B. Miscellaneous Fees <br />to determine valuation based oil (1) Driveway w/curb @ 87.30 :- <br />square footage,) (2) Drivcw~ly w/o curb (~ $17.(X1 <br />(1) Punnit Fee (3) Si~e Plan Review (eonmercial o, 17)0 $?9.00 <br />(2) 5% Slate Surcharge (,05 x A 1) (4) Additional Plan Reviews or Addcndums <br />(3) Sm]ctural Plan Review (,65% xAI) (5) investigation Fee <br />(4) Fire & Life Safely Plan Re. view (.40% x Al) (6) Reinapection Fee (q5 $25,00 <br /> <br /> (5 ' ' '~ vvlb,;bL (,~% ,, ~ (7) Olhcr blspcetiotls not Iisted above = ..... <br /> <br /> iOI \1 <br /> ~ 7~t~ RnCnII'r;__~../_~'~ s JCl, 3'7 <br /> <br />Valuation: <br /> <br /> 3-Z&9 <br /> <br />= <br /> <br />heruby certify lbat the above information is cermet and that I bare ~ad aM understand ~e In fomation Notice 1o Propo,:y Owners about Construction Respmsibililies on thc <br />reverse siile of I}tis form. <br />Na,l¢oI'A~licant~leasePrinO: ~rD~ ~ I ~ ~> ~k% ~}~ _Phone: ~ ~¢ "- ~(~ /'~ <br /> <br /> Site evalualio;~$, septic, electrical, plumbing and mechanical~ require ~e~rate pe~it~. Check with Mafiosi County f~u[lding Inspection ~fom q*~ilbng t}b~ application. <br /> <br />MC 1543 Rev. 11/91 <br /> <br /> <br />