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I FOR CITY VALIDATION <br />Received By: ~ ~ ~ <br /> Zoning Validation: d'~Y <br /> Date: ' / - / g -q~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( ) Accessory <br /> <br />Description of Work <br /> <br />Energy Path: <br /> <br />Square Footage -Basement: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />No. Stories <br /> <br /> Main Floor: <br /> <br /> I FOR CITY USE ONLY <br /> COMMUNITY <br /> DEVELOPMENT <br /> CENTER <br /> 285 Church St. NE - Room 132 ICity Setback Requirements: <br /> Salem, Oregon 97301 ~ , <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 _ ~ ~q"~ ~ ~' ~ ~.~]r ~,~'~ <br /> <br /> COMMERCIAL <br /> <br /> ( )Alteration ( )Sign ~ /~O ' <br /> ( ) Change of Occupancy ( ) O~er <br />~' ~~ ~ Is ~isa histofic~ building? Yes - No <br /> <br /> No. of Employees: Existing - New- ~ No. BO~ms: <br /> Second Flor: I Garage: O~er: I Height: <br /> <br />2. LOCATION OF INSTALLATION <br />Property Owner g {/~'~ .~ (d'~ (~ ~ 6 ~"[~fl/~ J~'t~t~,~ Mailing Ad~ess~ <br /> <br /> SuMivision <br /> <br />Mobile Home Park <br /> <br />Tax Acct. <br /> <br />Section ~//0}~ ~6 Township <br />Lot Width Lot Depth <br /> <br />EtS <br /> <br />Lot <br /> <br />Space # <br /> <br />Z°ne'e0/'t~' I Map <br />,rreg. Lot d~) Coruer ~t/0 <br /> <br />PhoneNo. ~Tq¢ //.,~Z <br /> <br />Cross Street <br /> <br />Block <br /> <br />Water Supply: <br />PfivateWell ( ) 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 />ia 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 />m a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Nam~ ~ Registration No. <br /> <br /> Mai'ing Address fa /~)"~ C~''~ ~u, ct-~., Phone 749 1/.3' z.. <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 />on square footage of project.) Valuation: $ ~. <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Sumharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />= 16,70 <br />= 07/7,/o <br /> <br />= S-cd <br /> <br /> Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />RECEIPT: q'~'~- ""~ - TOTAL <br /> <br />=$ <br /> <br />=$ ~,11. 90 <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): '__'"'l O /1~ Phone: <br /> <br />S iguatureof Applicant: ~'~ '7~ /~~~'~'~. Date: / <br />MC 15-73 Rev 1/95 <br /> <br /> <br />