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IFOR CITY V/fi~LIDA/TION <br />Received By: f~ ffdec~-~ <br />[Zoning Validation: .d~' <br />[Date: ~-~4 ~ ~ ~ <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MAR/ON COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem Oregon 97301 __ ~ ~ <br /> <br /> MARION COUNTY <br /> ~t~ ~IM~ IMQD~T~[ <br /> <br />FOR CITY USE ONLY <br /> <br />[~ft siaef' ~"~"t~ght Si""~e: <br /> <br /> RESIDENTIAL <br /> (,,~ddition <br /> ( ) Alteration ( ) Other <br /> <br /> ( ) Accessory <br />EnergyDescripti°n °f W°rk ~'Lc- fi N~. StoTS~ Path: <br />Square Footage -Basement: Main Floor: <br /> <br /> COMMERCIAL <br /> <br />( ) Relocation ( ) Addition <br /> ( ) Alteration <br /> ( ) Change of Occupancy <br /> <br /> { No. of Employees: Existing- <br /> ISecond Floor: <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br />v ,Ose of Structure: <br /> <br /> Is this a historical building? Yes <br /> <br /> New - [ No. Bedrooms: <br />~.or'e'~ SO~,) ]Other: <br /> <br />Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision <br /> <br />IMailing Address <br /> Tax Acct. No. /~ <br /> <br /> Lot <br /> <br /> J Space # [ P ~ <br /> } ~ne ~p. Map <br /> ~eg.~t ~ Comer <br /> <br />Mobile Home Park ~{.~/9~-~ ~ /~~ <br /> ~.~ ]Range <br />S~fion ~ ~ TownsMp , <br />~t Wid~ q/ ~t Dep~ /~ Acres <br /> <br />Phone No. <br /> <br />Cross Street <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 /> <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> Mailing Address .~/n,¢/~,%,__ Phone <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br />on square footage of project.) Valuation: $ ,~".~/°~7- 0'~0 <br /> <br />(1) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(5) ~ag Surch~ge, if applicable (.05~ x Al) <br />(6) Seis~c Su~h~ge = <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> {4) Other Inspe4:tions not listed above <br /> <br />RECEIPT: <br /> <br />=$ <br /> <br />TOTAL =$ <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 (Pie ~t%4'/_.~ Phone: <br /> <br />Signature of Applicant: ~~ ~ LT.. -a,- - / t,~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />