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12ITY VALIDATION <br />e~By: <br />IZoning Validation: <br />[Date: /-/9- ~6 <br /> <br />MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br />COMMUNITY DEVELOPMENT CENTER [ .... <br />285 Church St. NE - Roo. jlL132~ [City Setback Requirements: <br /> Salem Oregon 9730~--'~.~--~ ! i: .3 i.: , i :.' , 7:-,..,"N , <br /> L - I:L.~ ~f~' i~; ~ ~ .~l~nr~, Rear: <br /> 8:00am-n:30pm Phone 58~4~ ~ ~a a <br /> 24 hr, Inspection Line 58~ ~.~ ~t6: ~] ! .... ['~ght Side: <br /> FAX 588-7948 j [ } 1 , /~' t il.l .~ I <br /> <br /> BUILDING PERMIT APPLICAI't'0/N <br /> <br />COMMERCIAL <br /> ( ~"~dition <br /> ( ) Alteration <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br /> ( ) New <br /> ( ) Sign <br />( ) Change of Occupancy ( ) Other <br /> <br />RESIDENTIAL <br />( ) Addition ( ) Relocation <br />( ) Alteration ( ) Other <br /> <br />INo. of Employees: Existing - <br /> <br />( ) Accessory <br /> <br />Description of Work <br /> <br />Energy Path: [ No. Stories <br /> <br /> COUNTY <br /> <br /> Use of S~cmre: <br /> <br /> Is ~is a ~istodcal bu~di.g? Yes - <br />New - ] No. B~ms: <br /> <br />Square Footage -Basement: X~ MainFloor: I~.OO ~lr~'JS~condmoor: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />JMailing Address <br /> <br />Mobile Home Park <br /> <br />Tax ^ ct. Nog'7, m, o <br /> <br />Section W~ 3~'1 Township ~..~ J Range <br />LotWidth //~5~ LotDepth ~100 J Acres <br /> <br />Lot <br /> <br /> Space # <br />Zone~ , IMap <br />Irreg. LOt ~0 Comer <br /> <br />~honeNo. ~¢? 'o2~ Jd <br /> <br />Cross Street <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 />Business Name ~ Registration No.% <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. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br /> on square footage of project.) Valuation: $ ~. <br /> ( 1 ) Permit Fee <br /> (2) 5% State Surcharge (.05 x Al) = <br /> (3) Structural Plan Review (.65% x Al) = <br />JA-)~;;c & Li;~ $,d~y I'1,~, R~,l~w (.46¢6 x ^i)- ~/~ /t-'t.t-~ <br />(5) Zoning Sumharge, if applicable (.05% x Al) = <br />(6) Seismic Surcharge = <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />RECEIPT: <br /> <br />TOTAL <br /> <br />=$ <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 of Applicant (Please Print).'~/~_/JJ~--f'~t~ L~ ~...~_~__~_..~..~/-- Phone: ~'~O--/D~L <br />Signature of Applicant: L/J(_ __~--~-'~'~ 5 · i'~l"-~kfl~ ~_. , _ /q Date: 7-"--'/. ~-- ~. · <br />MC <br /> 15 <br /> 73 <br /> Rev <br /> 1/95 <br /> <br /> <br />