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FOR OFFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION ~ ONLY <br /> 220 High Street NE ~ ~ ' IGitySetbaekReqnir~evnenu: <br /> : Salem, OR97301 ~} ~.a ~ t~ ~ '~'// IRear: <br /> <br /> BUmD~GPERM~APPLICATIg~ V 4 19~3 ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 II~tlRlON ~OLtNYy <br /> BUILDI <br /> <br />1. Job Oescr!,ption .... ~'"~ l~l~p <br />RESIDENTIAL COMM'ERCIAL ( ) New <br />()Addition ( )Relocation ( )Addition ( )Sign <br />( ) Alteration ( )Demolition ( )Aher~tion ( )Demolition..~-..~/{/ <br />( )Ac~ssory ( )O~h~r ~ ( )ChangeofOceupaney <br /> <br />T~ss( ) of Rafter( ) No, gtoriea~ , ]OeeupantLoadorNtwnberofEmployee~ ~.,~, ~-~t'DF3 ]No, Bedrooms;l~'tgC~ ............. <br />.......... I ,".,,..2.~ t ~ ' / <br /> <br />2. Location oflnstallatlon <br /> <br /> D.~O/'O ~g ~73q> si~so. <br />Mobile Home Pa~ S~ce ~ <br />$e~ion I TownsMp J ~ ~nge~ ~ ~ Map Wamrgu~ly: <br /> ' PfivamWell ( ) Spring <br /> <br />3. Contractor Information <br /> <br />Propeay Owner I Mailing Add,ss ] Phone No: <br /> <br />( ) I will be my own Sea,ertl contractor. <br /> <br />with a coniractor who is registered withe Con~lmction Contraeto~ ~o~d will immediately notig¥ Marion County of th~ name of the contractor. <br /> <br /> ( ) IamurcgistcredbulldcrORth~authotizedrepresentatlveofaregiste~Ob~ilder. ,~ ~or~/ ~ qTO~>~ ~C4'~' .f~----/-/~ ~-,, <br /> CiOo5 ,~a.a ,OR' q7¢,.20 I ..,i,,,,,,,o'-- ~,WO~.~:..~ <br /> <br />4. Fee Schedule <br /> <br />VALUATION (See "Valuation Schedule" <br />to dele rlltiB¢ valuation based on <br /> <br />square foolage.) <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structural Plan P, evi~w (.6~% x Al) <br />(4) Fire & Life Safer7 Plan Review (.40% x A 1 ) <br /> <br />Valuation: $~3~--, ~' <br /> <br />B, Miscellaneous Fees <br /> (I) Driveway w/curb @ $7,50 <br /> <br /> (2) Driveway w/o curb@ $I7.00 <br /> <br /> (3) Site Plan Review (ecmmerclaI only) @ $79,00 <br /> <br /> (4) Add{fional Plan Reviews or Addendum <br /> <br /> (5) I~vestigation Fee <br /> <br /> (6) Relnspeefion Fee@ <br />RECEIPT:, (7) Other 0 ),)~.-Inspecti°ns ~'~ ~ ~-~n°t listed abqv~ <br /> <br />TO'fM. $ I-~-&U <br /> <br />rever~e aide of this form. <br /> <br /> plumbing ty Bulldog Ins <br />MC 15-73 Rev. II/91 <br /> <br /> <br />