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IN\kiti6 <br /> j- <br /> Linn County <br /> a_,,,,,,„ <br /> ~ PO Box 100 Rm 114 <br /> ; 300 SW 4th ST Rm 114 <br /> � ' ' Albany,OR 97321 <br /> `-W,'' Phone:541-967-3816 <br /> ti =' Web:co.linn.or.us <br /> Email:planoffice@co.linn.or.us <br /> APPLICATION FOR STRUCTURAL PERMIT DEPARTMENT USE ONLY <br /> Permit#: 5.?J. -, voi i;N., <br /> By: Date: <br /> This permit is issued under OAR 918-490-0050. Permits expire if work Is not started within 180 days of issuance or if work is suspended for 180 days. <br /> JOB SITE INFORMATION OWNER INFORMATION <br /> Address:1(o2 )y(i\! .jej fl - CV i /am the property owner doing my own work(initial).;i x,Cb <br /> City: fillAA GUN Owner Name: e 0.y-44+ Q,8190(ii 1Uv <br /> Parce!#: Mailingaddress:510 q.ifd turn cAR,L1f1.. jtLria.,Q $,4-�a <br /> Planning Approval:Yes No Conditions: Yes No City/State/ZIP: �ti1ti t f._. 07302 <br /> Is property inside city limits: e No City: Phone:cjf,j•-Lwf-3'7i1 : <br /> Is property in a flood plain : o Yes '1 'No Email: C) ) -tt_-G-}-ti)CO l,1aq .ni-4- <br /> OTHER APPROVALS <br /> Fire Department Approval Roads Department Environmental Health/Septic <br /> Information verified/approved? oY oN ❑Y ON Information verified/approved? oY oN <br /> Approval: Approval: Approval: <br /> Date: I Conditions: Yes No Permit number Date: IPermit#: <br /> (1) Valuation Information <br /> (a) Job description: t. L)rjt/t✓1 '2,0 • t, tVaitti(2- <br /> (b) Occupancy: .�- L <br /> (c) Construction type: C,tut., <br /> (d) Square feet: i¢DD <br /> (e) Cost per square foot(April ICC): (y-0.50 <br /> (f) Type of Work: 1/New ❑ Alteration❑ Addition❑Decommission❑ Repair <br /> (g) Is this a foundation ONLY permit? ❑Yes j?No <br /> (h) Is this a plan review ONLY? o Yes 'i iNo <br /> (i) Total valuation: 7.5)r()00 <br /> (2) Building Fees Contractor: !~ WWI" i i <br /> (a) Permit fee: �t.inll (AD G►-ufl�i ' E'G11iC��``�i�t <br /> Address: t I I ' ' <br /> (b) 12%surcharge: City/State/ZIP: I I <br /> (3) Plan Review Phone: . i <br /> (a) Plan review(permit fee x 65% ) Email: i s <br /> (b) Fire&Life Safety(permit fee x 40% ) BCD license: <br /> Subtotal of fees above: CCB license: rat tr y <br /> (4) Miscellaneous Fees <br /> (a) Seismic review—permit fee x 0.01 <br /> Total Due: <br /> I hereby certify that,to my knowledge,the above information is true and correct. All work to be performed shall be in accordance with all <br /> governing laws and rules. <br /> Applicant name: (`;o nA.4ri .f_ unJ'(ymaidVl _ <br /> Mailing Address: ?OM 'v)1 Y I Li In f tJ`l'1,i1 IA C (LQ sI- c <br /> City/State/ZIP: 5 Ll,U.M O;L g 1)U-7-- <br /> Phone: c/ .- ql(') - 3a'I <br /> Email: -l:Qit,i j -1)rAnA/toil-vii2_4 <br /> Signature: . ((fi/u_ 11/La� ;2_ Date: 47/ jy11 - <br />