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FOR CITY VALIDATION I <br />Received By: <br />Z~ning Validation: <br />Date: / -/~' -~' <br /> <br /> MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER [ <br /> 285 Church St. NE - Room 132 [City Setback Requirements: <br /> Salem, Oregon 97301 ! ** i <br /> 8:00am-4:30pm Phone 588-5147 __ ~ c-~ gr~9'~''~ ~ Rear: <br /> <br /> 24 hr Inspection Line 588-79 ~ ~ ' . k ~ Right' ' <br /> · SI ~ Side' <br /> FAX 588-7948 04~'-~(~~i ~ /t, i [ ' <br /> <br /> BUILDING PERMIT APPLIC~[~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 ~.~.~ <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( ) Accessory <br /> <br />Description of Work _.~"'",t~ r ~'~ ] i <br />Energy Path: I No. Stories <br />Square Footage -Basement: Main Floor: <br /> <br />COMMERCIAL <br /> <br /> ( )Addition ( )New <br /> ( ) Alteration (~Sign <br /> ( ) Change of Occupancy ( ) Other <br /> <br />Is this a historical building? Yes - No <br /> <br />INo. of Employees: Existing - New - <br /> Second Floor: [ Garage: <br /> <br />No. Bedrooms: <br /> <br />IOther: I Height: j~ f '7 it <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Property Owner <br /> <br />Subdivision <br /> <br />Mobile Home Park <br /> <br />Section ~,~_~" <br />Lot Width <br /> <br />Township <br /> <br />Lot Depth <br /> <br />Range <br /> <br />Acres <br /> <br />MallingAddress ~$e Az, ~4 ~P~'An,vu';l]¢ ~- <br /> <br /> O ~ Tax Acct. No.~~ <br /> <br /> Lot ~ / - Il- ~ - ' ' <br /> <br /> Space ~ <br /> <br /> ~ne ~. Map <br /> <br /> ~eg. ~t Com*r ~ <br /> <br />Phone <br /> <br />Cros S=et <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, 1 will immediately notify Marion County of the name of the contractor. <br />( ) I am a CONTRACTOR registered with the State of Oregon. <br />Business Name Registration No. <br />' 'Phone <br />Mailing Address 3/~,, ~,n~W_.t'~.t:lJ~- / .-JT,~"~ ~}~,~ ~ t:~O ~. d'~'L~~ ,~ ~. ~- "~."k.l I <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Name <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: <br />(1) Permit Fee <br />(2) 5% State Sumharge (.05 x Al) <br />(3) Structural Plan Review (.65% x Al) <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(6) Seismic Surehargc <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> <br />RECEIPT: (4)Oth~F~.7~°t listed above <br /> <br />=$ <br /> <br />TOTAL = $ <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 /> <br />Name of Applicant (Please Print): _~a g /%} J/t"/v._ ~ O_ r9- d Phone: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />