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FOR OFFICE USE ONLY <br />Received By: <br /> <br />Zoning VaL/dat/on: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:00am - 4:30pm Phone $88-5147 <br /> Code-A-Phor~ 588-7904 <br /> FAX 585-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COIVI?LETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. Job Description <br /> <br />City Setback Rgqttir~rneats: <br /> <br />Fmnt: ?ear: <br />L~t aide: 1 Right $ de: <br /> <br />FOR OFFICE USE ONLY <br /> <br />RESIDENTIAL COMMERCIAL ( )New Use of Structure: <br /> <br />( )Addition ( )R~locallon ( )Addition ( )Sign ~_ ___ ~( } f, <br />( ) Almmtion ( )Demolition ( )Alteration ( )Demolition <br />( )Accessory ( )Other ( )ChangeofOccupancy ( )Other <br />D~¢tipti0n of Work: <br /> <br />2. Location of Installation v~ <br /> <br />Su~ivision Dt Bl~k <br />Lot Wid~ Lm Depth Arms : '~g.-~ ~; Comer <br /> ( <br /> ) <br /> ......... Comm52~}yW~( ) City ( ) <br /> <br />3. Contractor Information <br />Prol~ty Owner I Mailing Address ,I Phone No: <br /> <br />) I own, reside in. et will reside in the completed structure. <br /> <br />I Marling Address: I Phone: ~ <br /> <br />Arghlmct name: [ Mailing <br /> <br />Phone: <br /> <br />4. Fee Schedule <br /> <br />A. VALUATION (Sea "Valuation $ehgdule" <br /> to determine valuation based on <br /> ~quare footage,) <br /> (1) Permit Fee <br /> <br /> (2) 5% State Surcharge (,05 x Al) <br /> <br /> (3) Structural Plan Review (.65% x Al) <br /> <br /> (4) Five & I..il~ SMety Plan Review (.40% x Al) <br /> (5) 7~oniag aumha~, ir applicable (,05% x Al) <br /> <br />Valuation: <br /> <br /> (I) Driveway w/curb (~_ $7,50 <br /> <br /> (2) Driveway w/o curb@ $17.00 <br /> <br /> (3) Site Plan Review (ccmlm¢~eiaI only) @ $79.00 <br /> <br /> (4) Additional Plan Reviews or Addendums <br /> <br /> (5) Investigation Fee <br /> <br /> (~) ReinaFeCfion Fee @ $25.00 <br />RECFIPT:, (7) Other JJiSl>eCtionsC~_~Q.''''~.n°l~ted above <br /> <br />I hereby ?nif~ ~at the above information is ~orr~ct and that I have read and und~mtand the ~fomatim N~ee m Property Owners about Cmstmction Resp~sibLldies on <br />mwrse mdc ot~ fo~. <br />Name o f Appllcant ~lea~t): ~q__ ~{9[' Ox [*d~''{~ Phone; <br /> <br />8ignalum of Apphcant: { I t 0 ~ ~ Dale; <br /> <br /> Site evaluations, septic, electrical, plumb~g md mecban{cal wo~ requi~ se~tate pe~its. Check wi~ Madon County BttildNg Impection ~fom mbmlu~g this <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />