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FOR"OFFIE~E USE. ONLY MARION COUNTY BUILDING INSPECTION [FOR OFFICE USE ONL~ <br />Received By-. ~,,~,~/.,/~ ~, ',.~-/~,~ COMMUNITY DEV~Ij~PMENT CENTER285 Church SV,,I~E] -¢t~om ! 32 City SeZback Req~ti~¢nts: <br />IZodngValidati°n: , ../'/~ , Salem.d~a/~t~. F~ti 1~ t Rear: /~n ( <br /> <br />2, Location oflng~llafion ~'ed ha/,% ~,~ qT~ 7/ <br /> <br />3. Contractor Information <br /> <br />Jif I hi~ sobco0~tm¢~ms, I will him only aub~ontraetors mglst~rcd wi~ ~e C~s~i~ ~cm~ B~rd. ~I o~nge my ~ and do ~e a general coot m~ot, I wi~ contract <br />wi~ a c~trac~r who is <br /> <br /> (b'~ am a rggistet~d builder OR th~ authorized mpmsentativo ora ~s~ b~. <br /> <br />4. Fee Schedule <br /> <br />A, VALUATION (Sec "Valuation Schedule" <br /> 1o dctcrmuic valuation based <br /> square footage.) <br /> (l) l'enuit Fe~ <br /> <br /> (2) 5% S/at~ Surcharge (.05 X A I) <br /> <br /> (3) Structural FL, xn Review (.65% x Al) <br /> <br /> (4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br /> - ' , If applacabte t,OS~o ~ ,, l ) <br /> <br />va~,~on; $.-~3/-7-. <br /> <br />Mbcelhneous Fees <br /> <br />(1) Driveway w/curb@ $730 <br />(2) Driveway w/o curb @ $17.~ <br /> <br />O) Sim Plan Renew (e~me~fl rely) ~ $79.~ <br />(4) Addifi~al ~an Renews or A~dmdms <br /> <br />(5) h~s~afim F~ <br />(6) R~s~ F~ ~ $~.00 <br />(7) ~r ~c~s not ~s~ abow <br /> <br />i hereby certify that the above information is correct and that I have read and understand the ]~formation Notice to Property Owners about Construction Responsibilities on the <br />reverse side of thi~ form. <br /> <br /> Sil¢ e aluatiot~, sopdc, electrical, plumbing and mechauicaI work require scperate permits. Check with Marion County Building Inspection before ,ubmitting this application. <br /> MC' 15-72t Rev 8/94 <br /> <br /> <br />