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FOR CT~y USE ONLY <br /> <br />zomg ~y: ~-/". c~l <br />Rec~i~ ~: ~f~ ~o~t:$ <br /> <br />JOB DESCRIPTION <br /> <br />RESIDENTIAL <br />~)New (~ Accessory <br />Alteration ( ) Relocation <br /> ( ) Addition <br /> <br /> 3150 Lancaster <br /> Salem, <br /> 8:00 ~ <br /> 24 <br /> FAX 588-7948 <br /> <br />BUILDING <br /> <br />( ) Addendum ( )New ( <br />( ) Other ( )Alteration ( <br /> ( ) Addition ( ) Sign <br /> ( )Other <br /> <br />FOR CITY USE ONLY <br />City Se~baeks: <br />Front: /~ /' Rear: J~ / <br /> <br />( ) Chauge of Occupancy or Use <br />( ) Manufacturdd Dwelling Pink <br />( ) Recreational Vehicle Park <br /> <br />Descripti°n ° f W°rk:A~(~ 0~4/~'f <br />Square Footage: Basement: 1st Hoor: 2nd Floor: <br /> <br />Number of Employees: Seating Capacity: Number of Bddrooms: Existing: Proposed: <br />2. LOCATION OF INSTALLATION <br /> <br />guMivision: I ~t: Block <br /> <br />~obilo Home P~ ( ) Mobil~ Home Subdiv~i~ Sp~e ~: To~ ~ Spies: <br /> [ W~r Su~ly: ( ) ~v~ We~ ( ) Co~m~ Well <br /> <br /> STION -- 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 undemand that I must <br />register as a construction contractor if the s~zucaure is sold or offered for sale before or upon completion. If I hire subcontractors, I will ~ only subcontractors <br />registered with the Construction Contractors Board. IfI change my mind and do hire a general contractor who is registered with the Consinsofion Contractors <br />Board, I wLl! immediatdy notify Marion County of the name of the contractor. <br /> <br />I am the AUTHORIZED REPRES .ENT,~sTIV~ of the plloperl~ ow~e$ or the eoatraetor. ..~ __ ~ <br /> <br /> S~et city: Zip: <br /> <br />Phoge: ~ <br /> <br />() <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br />Business Name (please print): <br /> <br />Mailing <br />Address: <br /> <br />RegisU-ation #: <br /> <br /> Street Cily: Zip: Phone: Fax: <br />FEES <br /> <br />A. VALUATION (See Valuation Schedule to determine the valuation <br />based on square footage of the project) $ ~ <br /> -=oboo. oo <br /> <br />(1) Permit Fee c~, ,~'V <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 /> <br />(6) Seismic Surcharge, if applicable (1% x Al) <br /> <br />Miscellaneous Fees <br /> <br /> (1) Addl Plan Review / Addendum ~ $50/hr, <br /> Minimum one-half hour <br /> (2) Reinspeetion Fee @ $50/per inspection <br /> (3) Investigation Fee <br /> (4) Inspections outside normal business <br /> Hours @ $50/hr, minimum two hours <br />~.~ (5) Inspections for which no fee is specifically <br /> Indicated @ $50/hr, minimum one hour <br /> (6) Additianal Sets of Plans @ SlOper set <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work <br />suspanded for 180 days. <br />Name of Applicant [Please lhSnt]: ~tgt. A4 ~(2t~b~ <br /> h4hfilingaddress? ]'~- l~lBXt q,,O_~., ~'e) A/_.W'~4 t~ <br /> <br />$ign~lurc of ~q~p 1i¢ ant ;~'T')x ~. J..~ ,.~ ~ Date: <br /> <br /> <br />