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FOR OFF. IC3yS~E O./NLYI MARION COUNTY BUILDING INSPECTION IFOR OFFICE USE ONLY <br />Retired lay: ~, .~/~. 220 High Street NE I <br />IZoning Validation:' c'd-~ -d~ -?~ ~ Salem, OR 97301 I_ ,-.,./ <br /> ....... ~ ' I I PrOnt: <br />line: 8-q .I $:00am: - 4:3Oom'Phim~ 5ag..5147 J <br /> FAX 588-7948 /~; ,; ~.- '"' <br /> <br /> 1. Job Description <br /> <br />2. LocationoflnstaHafion ~/~ /9r~. ~]73'a6; <br /> <br />3. Contractor Information <br />P~.yOwn~r~,~,~/~ ~$ /}b#'/)'O IM~lingAthl~ss I <br /> ( ) Io~,msJde~.~mside~e~mpl~mds~um. <br /> <br /> ( ) I un~nd ~a~ I m~t m~ster as a c~stm~ ~ ff~e s~um is s~d or ~emd f~ sa~ ~om or u~ ~plefi~. <br /> ( ) lwiR~myo~g~e~ <br /> <br /> ............ . . .... ........ { 4 r, 8q3-7 <br /> ( ) Iama~gxs~mdbufldcrOR~au~°~m~s~fiw°famV~.~' ~./~, Or~ ~7~ <br />Archi~ctname:,,, ~ ~/ ~ ~ , ~M~gA~mss: [Phon:e: <br />4. Fee Schedule <br /> <br />A, VALUATION (S~ "Valuation Schedule" <br /> to &mrmine valuation baaed on <br /> squam footage,) <br /> (1) Permit Fee <br /> <br /> (2) 5% Stare Surcharge (.05 x A 1) <br /> <br /> (3) Stractural Plan Review (,65% x Al) <br /> (4) Fire & Life Safety Plan Review (.40% x At) <br /> <br />B- IVlls~lane~,mS Fee~ <br /> (1) DHveway w/~b @ $7.$0 <br /> <br /> (2) Driveway w/o cu~ $17.~ <br /> <br /> (3) Sim Plau R~¢w (c~me~ ~ly) ~ $79.~ <br /> <br /> (4) AddiR~al Plan ~ews or Addmdms <br /> <br /> (6) ~m F~ ~ ~.00 <br /> ~) O~et ~s~fims not ~s~ a~ve <br /> <br /> hereby ~,enff?.~at~the above information is correct and that I have mad and unde~tand the Information N¢~c¢ ~o Propeay Owners about Constmc%n Respons bilides on the <br /> <br />SignatumofAppl/cam: / '-~-~--~ -~-"~/LI, /'~'~'~ Date: <br /> Si[e evaluations, septic, electrical, plumbing and mechanical work require Sel~fat~ ]~rmit~. Clm*k with Marion County Building Inspeclion before ~ubmitling this applieatinn. <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />