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F¢I~OR ................................ CrYY U~0~N~ . '~ r-.-_] COMMUNITyMARION COUNTYDEvELOPMENT,Cb~UERBUILDING INSPECTION ~.' ......................................................... FOR CITY USE ONLY <br /> <br /> * · Salem, Oregon97305,,, /S <br />, , 8:00am-4:30pm, IIiV ' <br />.................................. 24 hr. InSpection Line 373-443~ ~.~ , ! spoal'~l~T~T~-~L'~- 2~ <br /> <br /> JOB DRSCRUYrlON <br /> <br />RESIDENTIAL <br /> ~0 N*w <br />( ) a.~-ation <br />~ Addition <br /> <br />.(~) Accessory ( ) Addendum <br />RelOCation ~, Other <br /> <br /> gqume Footage: l~sement: 1st Floor: ~'~ 2nd Floor: <br />Number of Employees: ~e~ing C~pacity: <br />2. LocATIoN OF INSTALLATION <br /> <br />COMMERCIAL <br />( )New ( ) Multi Family <br />( ) Al~a'~tlon ( ) Addendum <br />) Addition ( ) sign <br />( <br /> <br />( ) Change of O~cup~ncy or Use <br />( ) Manuf~-tut~d Dwelling parle <br />( ) Recreational Vehicle padc <br /> <br />Use of Structure: ~ff.4~q ~. Occupancy: <br /> <br />Other: No. Stories: Urn: <br /> <br />Height: <br /> <br />Number of Bodrooms: Existing: Proposed: <br /> <br />CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am ~e PROPERTY OV~'ER ~nd own, reside in, or will reside in the ¢omple~d structure and will b~ my OWn general conh'actor. I understand that I must <br />r~glst~ ~8 a coratruction contractor if the struclur~ is sold or offered for sale before or upon completion. If I hire subooatnactors. I will hire only subeonlractors <br />registered with the Construction Contraotors Bo~rd. lfI change my mind &nd do hire a general contractor who is regi~tereA with the Con~lu0lion Contr~tora <br />Board, I wilt immediately notify Marion County of the rmmo oflhe contractor. <br /> <br />() <br /> <br />() <br /> <br />I am the AUTHORIZED REPRESENTATIVE of the propot~ty owner or the contnmor. <br />Business Name (pleas~ print)__ __ <br /> <br />Mailing Address: <br /> <br />S~reet City: <br /> <br />BusinessI mn a CONTRACTOR registered with the St. of Oregon.Name (please print,: __ "' J ~J ~ g0m~2~'~)/' <br />M~,ing MARION COUNIY <br />Address: BUILDING INSPECTff3N <br /> sm~ city: Zip: Phone: Fax: <br /> <br />4. FEES <br /> <br />A. VALUATION (See Valuation Schedule to determine the valuation <br />baeed on square footage of the project) $ / ~"/.. i q. <br /> <br />(1) Pcn'nit Feo <br />(2) State Surcharge (5°4 x Al) <br />(3) Structural Plan Review (65% x Al) <br />(4) Fife and Life Safety Plan Review (40°.4 x Al) - <br />(5) Zoning Surcharge, if applicable (6% x Al) <br />(6) SUrCharge, if applicable (1 ~ x Al ) <br /> <br />B. Miscellaneous:Fees <br /> <br />(1) Addl Plan Review / Addendum (~ $50/hr, <br /> Minimum one-half hour <br />(2) ReinSpection Fee @ $50/per hz~l~'ction <br />(3) Investigation Fee <br />(4) Inspections outside normal business <br /> Hours @ $50/hr, minimum two hours <br />O) InSpections for which ne fee is Specifically <br /> Indicated ~ $50/hr, min~um one hour <br />(6) Additional Sets of Plans (~ $10 per set <br /> TOTAL <br /> <br />I hereby certify that the above information is correct. Permits are non.transferrable and expire if work is not sturted within 180 days of issuance or if work <br />suspended for 180 days. <br />Name of Applicant t?lease Prinq: <br /> <br />Signature ofApplicant:/'/~ ~. ,ff -- - -],4 . )/]. ~ fi, ~.~ Date: /.,13 /~'~1 <br />MC15-73 Rev9/98 ~-c~n$~'-- <br /> <br /> <br />