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IRFOR CITY <br />Izonl.g <br />~Dat~: __/t -~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> ~85 Church S{, NE - Room 132 <br /> Salem, Or~gon 97301 <br /> 8:00am-4:30p~n Phone 588-5147 <br /> ~l- hi'. Insl:.~ .on Line S88-7904 <br /> FAX $88-7948 <br /> <br /> BUILDING PER] ~IIT APPLICATION <br /> <br />COMPLE'YE ALL SECTIONS, 1 THROUGH 4 <br /> <br />FOR CITY USE ONLY <br /> <br />L lOB DESCRIPTION <br /> <br /> RES IDF~NTIAL coMMERCIAL ] Use of StRicture: ' - <br /> ( ) Addition ( ) Relocation ( ) Addition J ( ) New <br /> (~ Accessory <br /> ( )ChangeofO~cup~ncy ( )Ottier <br /> <br />~ergy Path; J N0, Stories / [ ,, , NeW- <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Block <br /> <br />Water Supply: <br />Pdvate Well ( ) Spring <br />Community Well ( ) City <br /> <br />3. CONTRACTOR LNFORMATION -- PLEASE INDICATE WI 10 IS DOING THE WORK <br /> <br />j m,~ngAd~,, ,J.~om~ <br /> <br />,/eY ~hone '76 ¢- 7 74c/ <br /> <br />4. FEE SCHEDULE <br /> <br />(1) Additional Plan l~vi*ws or Addendums <br /> <br />(2) Investigation Fee <br /> <br />O) I~¢inspeedon Fee ~ $25,00 <br /> <br />(4) Other Insggtions not I~d ahoy, <br /> <br />=$ <br /> <br />Name of Applicanl (Please Prin}~,C~l~ txQ ~J~ g 0,_ ~, <br /> <br />I hereby certify that thc above information is correct, <br />Permits ace non-transferrable and expire if work is not started within 180 days of issuance or if work ia ~usp~nd~d for 180 days. <br /> <br /> __vtio~: _~ q-77qq <br /> <br /> <br />