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Received By: L~t~t.~ .~ ~ 285 Church St. NE - Room 132 <br /> <br /> .~ / / ~ ~ I Salem, Oregon 97301 <br />Zoning Vahd.ation:. ~ As,~ I 8:00an~pnJt~hl[l~ 5~5/~7~1f/ I~ ~ <br />Date: /..9_ -...,c6,-~.5~' [ 24hr'~t~'g~85~'Tq~4~/ [~ I~) <br /> BUILDING PERMI~[~Pi~C~~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />,dA <br /> <br /> MARION CO[JNI'Y <br />COUMERCIAL BUILDING INSPECIIO~ <br /> ( )Addition ( )New <br /> <br /> ( ) Alteration ( ) Sign <br /> ( ) Change of Occupancy ( ) Other <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> <br /> ( ) Addition <br /> <br /> ( ) Relocation <br />( ) Alteration ( ) Other <br />(L,~ccessory <br />Description of Work <br /> <br />Energy Path: <br /> No. <br /> Stories <br /> <br /> -Basement: [ Main Floor: <br />Square <br /> Footage <br /> I <br /> <br />J N= of Employees: Existing - New - <br /> I Second Floor: Garage: <br /> <br />IFOR CITY USE ONLY <br />City Setback Requirements: <br /> <br /> Front: [Rear: /~ ! <br /> Left Side: [ Right Side: <br /> <br />q .-oc.x}jq <br /> <br />Use of Structure: <br /> <br />Is this a historical building? Yes <br /> <br /> No. Bedrooms: <br /> Other' '~"'~9~'/O~/~'1 Height: <br /> <br />2. LOCATION OF INSTALLATION <br />Property Owner ~t.~ao/5/~/ ~.~,~ffg::~..~- } MailingAd~ess~ ~~/~ <br /> <br /> SuMivision _ I Lot <br /> Mobile Home P~k ~~~ ~~~. I I Space~ t ~ 7 <br /> <br /> Section ~0 :Township ~ ~ ;:a~e /~ ~ne ~ IMap <br /> ~tWid~ / I ~tDep~ ~'l ]Acres ~ I~g.~t ~ Comer <br /> <br />Phone No. ~;~'/__ <br />'CrossStreet MI>/ C~'~/~'' <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring ( ) <br />Community Well ( ) City (°) <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I undemtand that I must register as a construction <br />contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br />I am a CONTRACTOR registered with the State of Oregon. <br />Business Name Registration No. <br />Mailing Address Phone <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Mailing Ad ~ Phone <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ ,~o'~/t.n~, ~ <br />(1) Permit Fee .6,/~/~ .5'-10 <br /> <br />(2) 5% State Sumharge (.05 x Al) = s~. ~3 <br />(3) Structural Plan Review (.65% x Al) = ~ ~, 93 <br /> <br />(5) Zoning Surcharge, if applicaNe (.05% x Al) = <br />(6) Seismic Surcharge = <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />=$ <br /> <br />TOTAL =$ <br /> <br />8o7.5¥ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Print): <br /> <br />Signature of Applicant: <br />MC 15-73 Rev~ <br /> <br />Phone: <br />Date: <br /> <br /> <br />