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IFOR CITY VALIDATION <br />R;ceiv'ed By: <br />Zoning Validation: <br />Date: / - o,°~t/ - q ~' <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> <br />( ) Addition ( ) Relocation <br /> <br />( ) Alteration· ( ) Other <br />( ~Accessory <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Sal~Oret~gon 97301 <br /> 8:00am-~ ~]lallg~{[l~5147 <br /> <br /> BUILDiNG~T~APdPL~IC ~T~ <br /> <br />COMMERCIAL ~,II,lAn__.lON <br /> ~UiLOINs <br /> ( )Addition <br /> ( ) Alteration ( ) Sign <br /> ( ) Change of Occupancy ( ) Other <br /> <br />Energy Path: } No. Stories J No. of Employees: Existing - New - <br />Square Footage -Basement: Main Floor: [ Second Floor: Garage: <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Left Side: ~idc: <br /> <br /> Use of Structure: <br /> <br />IIs this a historical building? Yes <br /> <br /> No. Bedrooms: <br /> Other: <br /> <br />- No <br /> <br />Height: /~. ! <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Property Owner V/~/Ld~ ~_/i/q,Z~.t...d ] M~,ing ^ad,ess <br />,ob ^d ess q// <br /> <br />Subdivision <br /> <br />Mobile Home Park <br /> <br />Lot Width /00 / Lot Depth 7 t9 Acres <br /> <br />q T~/~ <br /> <br />Pbo.e~o. 77 <br /> <br />Cross Street <br /> <br />Lot ~ Block <br /> <br />Space# <br /> <br />Irreg. Lot <br /> <br />Map <br /> <br />Comer <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 thc 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, 1 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 />Busi~,s Name ~ .n Registration No. <br />p 'tv I ,4' w',v ,,t e ¢ 0 <br />Mailing Addr0.ss ~ . , ~ ~/ Phone <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br /> MailingAddress~p/j~t,V,] ~./ Phone 7~:~-7 7qV <br /> <br />4. FEE SCHEDULE <br /> <br /> A, VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) <br />(I) Permit Fee <br />(2) 5% State Sumharge (.05 x Al) = <br />(3) Structural Plan Review (.65% x Al) = <br /> <br /> ~ c ety ' AI~ ~,~-- = <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />Valuation: $ <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />TOTAL <br /> <br />=$ <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 (Pleas~: 7^~ Phone: <br />Signature of Applicant: / o-'t.~t.,.'/r.~ ~V (_}~ri, x,,~a~.,,' Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />7 t, t- 7 7 5RTP <br /> <br /> <br />