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g ~o~crrv~s o L¥ . <br />I R~ #:__ Amount:S__ <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTLAL <br />( ) New () Accessory <br />( ) Allerafion ( ) Relocation <br />( ) Addition <br /> <br />D~scription of Work: /~ ~ ,~,O,D~.~ <br /> <br />Squar~ Footage: Ba~mont: 1st Floor: <br /> <br /> MARION COUNTY BUILDING 1NSPEC'I'ION <br /> COMMUNITY DEVELOPMEIVf CENTER FOR CITY USE ONLY <br /> 3150 Lancaster Dr. NE - Suite C ~ Citv Setbacks: - <br /> Salem, Oregon 97305 - R~ar <br /> 8:00 am- 4:30 pm /~9~/~/~ ~F~ ~;ght: <br /> 24 -' <br /> <br />Addondum ( )New ( )Multi~ (//]//~)Chaa~gaofO~¢upancyorUso <br />Other ( ) Alteration ( ) Addend~O~t~J~( ) Manufactured Dwelling Park <br /> ( ) Addition ( )$ign %t//9~ Recreational Vehiel~ Pank <br /> <br /> 2nd Floor: Other: No. $torios: Unit~: Height: <br /> <br />Number of Employes: Seating Capacity: Number of Bedrooms: Exiating: Proposed: <br />2. LOCATION OF INSTALLATION <br /> <br />CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE ~ ~ORK <br /> <br />Board, I will immediately notif~ Marion County oftl~ name of the contractor. <br /> <br />( ) I am rite AUTHORIZED REPRESENTATIVE of the prol~r~y owner or ~he co~traelor. <br /> Busings Name (pleas~ paint). <br /> <br /> Mailing Address: <br /> Street City: Zip: Phone: <br /> <br />() <br /> <br />I am a CONTRACTOR registered with tho State of Oregon. <br />Business Name (please prim): <br /> <br />R~gislration #: <br /> <br />Mailing <br /> <br />Str~6't City: Zip: Phone: Fax: <br /> <br />4. FEES <br /> <br /> A. VALUATION (Sec Valuation Schedule to de~ine the yaluation <br /> based on squa~ footage of the projeet) <br /> <br />(1) Permit Fee <br />(2) State Surcharge (5% x Al) <br />(3) Structural Plan Review (65% x Al) <br />(4) Fire and Life Safety Plan Review (40% x Al) <br />(5) Zoning Surcharge, if applicable (6% x Al) <br />(6) Seismic Sm'charge, if applicable (1% x A 1 ) <br /> <br />~. Mi~ellananus Fees <br /> <br />( 1 ) Addl Plan Review / Addendum @ $50/hr, <br /> Minimum one-half hour $ <br />(2) Reinspeetion Fee (~ $50/pur inspection $ <br />(3) Investigation Fee $ <br />(4) Inspections outside normal business <br /> Hours @ $50/b.r, minimum two hours $ <br />(5) Inspections for which no fee is specifically <br /> Indicated ~ $50thr, minimum one hour <br />(6) Additional Sets of Plans ~ $I0 per set $ <br /> TOTAL $ <br /> <br /> r <br />I hereby certify that the above information is correct. Permits are non-transferrable ~ttzdxpjffe ffwork is not start~ within 180 days of issuance or if work <br /> for <br /> <br />MC 15-73 Rev 9/98 <br /> <br /> <br />