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'1 FOR'CITY VALIDATION <br />Izo~ing Validation: v t~ <br />[Date: '7/}..-/q k, <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTI'~BD~NC~:~~N i FOR CITY USE ONLY <br /> 285C"'u['~ '"~, ,~¢~m,,l;,~ ,., ii'ii;i.]] [City Setback Requirements: <br /> Sal 9'/301 <br /> <br /> 24 hr' l~""'l~:~°n Ik[l~ ~88"~99 <br /> FAX $88-7948 <br /> <br /> RESIDENTIAL COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> ( ) Alteration ( ) Other ( ) Alteration <br /> <br /> ) ~ccessory ( ) Change of Occupancy <br /> <br /> · ~' No. Stories -- ] No. of Em~ooyees: <br />Energy <br /> Path: <br /> Existing <br /> <br /> -Basement: I Main Floor: I Second Floor: <br />Square <br /> Footage <br /> I <br /> I <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Property Owner <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br />UseofS tmcmre~~O <br /> <br />lis this a historical building? Yes <br /> <br />New - <br /> <br />Garage: <br /> <br />No. Bedrooms: <br /> <br />IOther:. "~O0~I~ght: <br /> <br />] Mailing Address 26~"- X <br /> <br />Tax Acct. No. fl. '9:5 ~ 3 ! <br /> <br />Ph°ne <br />Cr°ss Street <br /> <br />Subdivision <br /> <br /> 30 - T°wni P - R nge c,O <br />~t Widm ~ ~t ~pm / ~ ~ Acres I=g. ~t <br /> <br />I5-6x'~5- ooo <br /> Lot <br /> Space # ~Ma7~ <br /> I co~ner rl o <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring <br />Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- 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 understand that I must register as a construction <br />contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br />( ) I am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business jName Registration No. <br /> <br />'l[lailing'Address~ - ~-- ,~ .,.-t. ~ ' Phone <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Name <br />Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br />A. B. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ ..~.,~l.~. <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(5) Zoning Surcharge, if applicable (.05% <br />(6) Seismic Surcharge ) <br /> <br />= 28'.'12 <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> 9 7 7 7 TOTAL <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />Name ofApplicant(PleasePril~' ~'~¢'~-~ ~ ~:>~ Phone: <br />Signature of Applicant:~ .~/'~.~ ~.~::~'~ Date: <br />MC 15-73 Revl/lt~ <br /> <br /> <br />