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IiF. OR CITY VALIDATION MARION COUNTY BUILDING INSPECTION [ FORCITY USE ONLY <br /> ,,7 / COMMUNITY DEVELOPMENT CENTER <br /> eceived By: //2}~ 285 Church St. NE - Room 132 ]City gelback Requirements: <br /> ff~/~/~,'l.-' Salem. Oregon 97301 I <br /> oning Validation: ,~,~' 8:00am-a:30p-- ~'o e588-$147 <br /> <br /> COMPLETE ALL SECTIONS, 1 ~ROUGH 4 ~ ,. ' <br /> ' <br /> <br /> RESIDENTIAL COMMERCIAL ,.. IlqA[:llOtll ~ -'" us~ofstructure: · <br /> ( )Alteration ( )Other ( )Algration( )Sfg~'//(' <br /> (~Acces~,ol'd ( )Chang¢ofO¢~upancy ( )Other <br />l~,ptionot'Work ~ ~ ~'" ~ ,/~;~ ~1 I'¥~";iaahts~o~c~b,il0ing7 Ye~ - No <br /> <br />2. LOCATION OF INSTALLATION i ff~d. aL~c.,,~, d/,~. ~P.~.'~ <br /> <br /> ..... i, " <br /> <br />S~fio~ ~¢ Town*ip ~, Rang* ~' ~n.[ ~' Map ~at,tSu~ly: <br /> , . Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE ~,VHO IS DOING THE WORK <br /> <br />am a, AUTHORIZED REPRE~IEN~TIVE of th~ property owner ut ~on~ractor. <br /> <br />4. FEE SCHEDULE <br /> <br />(2) Inve~tigati0rl Fee <br /> <br />(3) ReinspeCti0n Fee @ $25.00 <br /> <br />1 hereby certify that the above information is correct. <br />Permits are non-transt~rrable and expire if work is not slatted within 180 days of issuance or if work is suspended tbt 180 days. <br /> <br />Signatur* of Applicant: [~W~ Date: <br />MC 15-73 Rev 1195 <br /> <br /> <br />