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~ ~ ~OR cITy USg ONLY ~ MARION COUNTY BUILDING INSPECTION <br /> <br /> ~ Received By'~gfg*tl II..e-- Date: l --/.3 _-~ COMMUNITY DEVELOPMEIqT CENTER <br /> <br /> ~ New ( ) Acce~ ) A~dum / )N~w '~ ~fly ( )~of~U~ <br /> ) ~ ( ) Ralo~fion ) ~er [ )~ ( )A~d~ ( <br /> Addition ) Add.on ( ) Si~ ( ) ~mafion~ V~le ~ <br /> <br /> Nmher of~: Ex~g: <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br /> <br />Number of F~nployc~z: Sealing Capacity: Proposed: <br />2. LOCATION OF INSTALLATION <br /> <br />( ) Mobile Home ~ ( ) Mobile Home Su~ivisi~ sP~e ~: To~ ~ S~s~ <br />M~: ~f~ne: ~F ~P~IS~e: ~F () AC .; UOB~ ~ () N <br /> <br />~: ~00 ~ O~ ~ ~ P~cel~: ~00 [ Wat~pply: ( ) ~v~WoI1 ( > C~WolI ~ <br /> I <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />() <br /> <br />Board, I will irmmediately notify Marion County 0fthe name of~he ~ont~or. <br /> <br />Busine~ Nam~ (please print) <br /> <br />Mailing Address: <br /> Street City: Zip: Phone: <br /> <br />() <br /> <br />I am a CONTRACTOR registered with the State of Oregon.__ , <br /> <br />Mailing <br /> <br /> S~ CiW: Zip: ~onc: F~ <br /> <br />4. FEES <br /> <br />A. VALUATION (See Valuation Schedule to ~in¢ the valuation <br />based on square footage of the project) $ ~ <br /> <br />(1) Permit Fee .~3 I, O O~ <br />(2) State Surcharge (5% x Al) I L, .$~, <br />(3) Structural Plon P~view (65% xA1) ~. t ~",/~ <br />(4) Fire and Life Safety Plan Review (40% x Al) <br />(5) Zoning Surcharge, if applicable (6% x Al) <br />(6) Seismic Surcharge, if applicable ( 1% x A 1 ) <br /> <br />Miscellaneous F~es <br /> <br />( 1 ) Addl Phm Review / Addendum ~ $50/hr, <br /> Minimllm one-half hour <br />(2) Reiuspection F~e @ $50/per inspection <br />(3) Investigation Fee <br />(4) Inspcctious outside nonual business <br /> Hours ~ $50/hr, minimum two hours <br />(5) luspo:tious for wlfich no fee is specifically <br /> Indicated @ $50/hr, minimmn one hour <br />(6) Additional Sets of Plans ~ $10 per se~ <br /> TOTAL <br /> <br />I hereby ce~ify that thc above information is correct. Permits are non-transferrable and expire if work is not started within t 80 days of issuance or if wo <br />susponded for 180 days. <br />Name of Applicant tPlease Print]: ~=[O r j i'F~J~ r ~'~['~ ], { O I'~ . <br /> Mailing Address: P,O, I':kcvv ?~% D~u~,~_~)!viO~- 'e:~_gD~~' <br /> Phgne: ~ ~ <br />SignatureofAppticant:/~,'~----~ ~ Date: 1- <br />MC 15-73 Rev 9/9g <br /> <br /> <br />