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IFOtl OFI~, ICE USE ONLY <br /> <br /> Zoning Validation: <br /> Date: ;,; <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> <br /> 8:00artl - 4:~0lml Pheme ~88.5147 <br /> Code-A-Phone 588-7904 <br /> FAX $88-7948 <br /> BUILDiNG PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 TI-~OUGH 4 <br />1. Job Descrtpt~On <br /> <br />FOR OFFICE USE ONLY. <br />Clay 8~baek R,qulre~nelat~: <br />Front:" g~r: ' <br /> <br />RES]D I{NTIA L COMMF~CIAL i" )New Use of Strtlcture: <br />( !)Addition ( )R~location ( )Addition ( )$iga <br />() Alteratio~ ( )D~,molilion ( )Almtalion ( )l~mo]itioo <br />(:) ^~.~.sso. (~.)Ot~er~cb6y 5~ ~ ( )C~$eofO~e,V..cy ( )Other <br />Deacript[on of Work: <br />Tmsi( ) of Rafmr{}~) '1No. Slofi*s /" ' [OeeapantLoadofNmmberofErnployeea <br /> <br />3. Contractor I~aformafion <br />Pr ~Ry Ov~ne.,t <br /> <br /> ) ! wi21 he ~y own ge~leral contra <br /> <br /> (2) Driveway w/o curb @ $17.00 = <br />,(3) Site Plan Review (e~nrnerdal only)@ $79.00 -- __ <br /> (4) Additional Plan Rc,fiew~ or Addcndum$ = <br /> <5) Investigation Fee = <br /> (6) ReinsFection Fee @ $25.00 = -- <br /> (7) Other IJaspectlons not listefl above <br /> RECEIPT;. TOTAL <br /> <br />:square footage,) Valuation: <br />'(1) l~nnit F~ <br />(2) 5% State Surcharge (.05 x Al) = <br /> <br />(4) Fig & ~fe S~ety Plan Review (.~% xAl) = <br />(5) ~fing Surcha~e, if a~eable 605% x Al) = <br /> <br /> hereby .¢¢ai¢~ .t~. at. the above i~formatioa i~ m~t ~d ~at I have maa and under,nd ~e ~fo~a~m N~ce m Pr~eny Owners a~t Cmslmcfion Respmgib~J les m ~e <br /> <br /> S e evaluations, sepue, elecr cai, plumbing ~d mechanical wo~ ~mm sc~rat~ ~i~- Check wire Marion Couoty Bdld~g ~ns~ctkm ~fot¢ ~ubmitt~g this agE'cation. <br /> <br />MC 15-73 Rev. 11~1 <br /> <br /> <br />