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DFOR OFFIQE USE ONLY <br />Received By: [v ~ ~:4je..~ <br />Zoning Vahdation: ~' <br />a~:~ /~-'~ ~3 .. <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> $:00~n - 4:30pm Phon~ 588-5147 <br /> Cod~-A-l~o~ 558-7904 <br /> FAX 588-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. Job Description <br /> <br /> FOR OFFICE USE ONLY <br />ICiW Setback Requirements: <br /> //, JR. : /0' <br /> <br /> )Addition ( )Re. locat~n ( )Addition ()Sig~) ~.~ <br /> ) Alteration ( ) Demolition ( ) AlteratiOn ( ) Demolition <br />(~Aeeeastay ( )Other ( )ChalageofO¢ctlpanay ( )Other <br />DescriptiOn of Work; )~-~ ~"S <br />Tress ( ) or Raffler ( ) No, Slot£es Number of Employe~s No, Bedrooma:,, <br /> Second Fkor: I O that: IHeight: ,./0~ <br /> <br />Square F~t,~l~ Basement: I Mail* <br /> <br />2. Location of Installation <br /> <br />335 , <br />Subdivision ' <br /> <br />Se~m To.gNp ~ge Zme Map Wa~r Su~ly: <br />Lot Wldm ~t Lot ~p~ <br /> <br /> Contractor Information <br /> <br />(~ I om, m~e h. or ~ reside ~ ~e empleted ) I ~nd ~a~ ~ must m~ster as a ~n~[m~ cmmc~ ff~e a~re is ,oM or offered for gale befo~ or u~n <br /> <br /> ) I wiR be my om g~er~ <br /> <br /> If I hire subeontraeton, I will him only subcontractOrS ieglste4md with the Comtmction Contractors Board. If I change my mh~d and do Mre a general contraCtor, I will contract <br /> with a contractor who is reglstemd withe Con~troerion Contractors Board, and w~[l immed/ately ~¢ify Marion County of the name of the contractor, <br /> <br /> ~) I am a registered builder ~R ~he aufiaofii~d I~pm~tat~ve Of a ~gistared buildex, - <br /> 4I.' Fee Schedule ,. <br /> A.' VALUATfON (See "Valuation $ch~dale" B, Miscellaneous <br /> to de~rmine valuation ba~ed on <br /> ~qua~ footage,) Vatuation: <br /> <br /> s. baw (,0s Ai) <br /> (~) Structural Plan Review (,66% x Al) = __ <br /> (4) Fire & Life Safely Plan Review (.40% x Al) <br /> (5~ 7~Jng Surcharge, if applicable 605% x A 1 ) = __ = <br /> <br /> hereby certify that the above informal~ is correct and lhat ! have l~ad and understand the l~formatlon Notice to Property Owners about Consm~¢tio*~ ResponsibLbties on the <br /> <br />Name, ol' Applicant (Pta~,~ Print), ' ' [~- r ~- ~' , .... Phone: 7gq'- ?qq ,,_ <br /> <br />MC 15-73 Rev, 11/91 <br /> <br />(1) Driveway w/curb@ $7,50 <br /> <br />(2) Driveway w/o curb @ $17,00 <br /> <br />0) Site Plan Review (¢ommerclal only) <br /> <br />(4) Addi6onal Plan Reviews or Addmdums <br /> <br />(6) Reina~fim Fee ~ $25.00 <br /> <br />~) O~er ~s~cfi~s :~ot listed a~ve <br /> <br /> <br />