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FOR CITY VALID,~TIONI <br />Received By:. _/~g%l? / ~n/ <br />Zoning Validation: .,e..,,O" . <br />Date: / '~ ~~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br />RESIDENTIAL <br /> ( ) Addition ( ) Relocation <br /> <br /> ( ) Alteration ( ) Other <br /> ( ~Accessory <br />Descripfion of Work /d~ ~ofies~ ~'~"1 St H ' ~'~ ~' <br /> <br /> -Basement: [ Main Floor: ~ Second Floor: <br />Square <br /> Footage <br /> I <br /> <br />MARION COUNTY BUILDING INSPECTION l FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. ¢',{-~t~-r~,l~gm 132 ICity Setback Requirements: <br /> Salem, O 0r~i¢~ ~"~ .r"~t .... I ' <br /> ' ./' ,' ' :~' ~ ~ Front: Re~: <br /> <br /> BUmD~G PE~IT APPLiCATI~ <br /> <br /> COMMERCI~ ] Us6 of S~cmre: , <br /> ( ) Addition ( ) New <br /> <br /> ( ) Alteration ( ) Sign <br /> / <br /> ( ) Change of Occupancy ( ) Other <br /> <br /> I Is ~is a histofic~ buil~ng? Yes No <br /> New - ~ No. Beams: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />,ob ^d ss c )?. gb <br />Su~ivision <br /> <br />Mobile Home Park <br /> <br />Lot Width i~.~~' [ Lot Depth ~q.~. ¢0 <br /> <br />Acres <br /> <br />Ta~ Acct. ~o. .5"1 Y ? ~tOO O <br /> <br />Lot <br /> <br />Space # <br /> <br />Map <br /> <br />Comer <br /> <br />Irreg. Lot ~/tO <br /> <br />Cro,sS~eet sr Zle/,o~.¢ £eL <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 genera/contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br />I CONTRACTOR registered with the State of Oregon. <br />am <br />a <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 />(I) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Structural Plan Review (.65% x Al) = <br /> <br />(5) Zoning Surcharge, if applicable (.05% x Al) = <br />(6) Seismic Surcharge <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 /> <br />Name of Applicant (PI~'~'~F'~ ~.L~C i ~'~C K- ~"')(-~ D Phone: <br />Signature of Applicam: ~.~~j~'~ ~~/9'?/2 ~,~--~ Date: <br /> <br />MC ~5-73 Rev 1/95 ~--~/ <br /> <br /> <br />