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FOR OFFIC~ USE ONLY <br />· Received By: <br /> [z6ning Validation: <br /> ,Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Sue, et NE <br /> Salem, OR 97301 <br /> <br /> 8:00am - 4;30pm Phone 58845147 <br /> Code-A-ph~me S88-7904 <br /> FAX 588-7948 <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 TI{ROUGH 4 <br />1. Job Description <br /> <br />FOR OFFICE USE ONLY <br />City Setback R~q~di~a'nent~; ........ <br /> <br />2. Location of Installation <br /> <br />Private Well ( ) Spring <br /> <br />3, Contractor information <br /> <br />ff I ~ sunbeam, I wffi him on~ subc~tm~ ~81ster~ wi~ ~e ~ Cm~wm BtaM. ~ I change my ~d and do <br /> <br />wi~ a c~tmctor w~ is ~$s~ wi~g C~atmcfi~ C~c~r'a B~M, ~d ~1 ~ed~t~y n~y Ma~n County of ~e name of ~e c~trac~r. <br /> <br />4. Fee Schedule <br /> <br />to &te~d'valuafion baa~l on <br />squa~ footage.) <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surchaega (.05 x Al) <br /> <br />(3) Structural Plan P~view (.65% x Al) <br /> <br />(g) F m & Lff~ Safety Plan Rvvi~w (.40% <br /> <br />Vahat~on: <br /> <br />(2) Driveway w/o curb @ $17,00 <br /> <br />O) ~ Plan Renew (emme~al ~ly) ~ $79.~ <br /> <br />(4) Addi~al Plan Reviews or Addmdms <br /> <br />(5) ~s~fi~ Fee <br /> ~fi~ Fee ~ 825,00 <br />~) O~er ~s~efims not ~smd above <br /> <br />TOTAL <br /> <br />I hereby .c,enff~y.~at?e a~ove inf~orm afl__on is cor~ct and that I have read and undemand the Information Notice to Prop~r~y Owner~ about Construction Respon* bilities on the <br />Name of Applicant (P ease PridD: ]' .l~'t~j ~,IL rh~e 3($-/7tl <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />