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IFOR CITY ~ALIDA~.ION <br />lleceived'By: <br />Zo~ng Validation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER I <br /> 285 Church St. NE - Room llt3~ ICity Setback Requirements: <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 5884 <br /> Inspection Line 588-7 a <br /> 24hr. FAX 588-7948 --~'~ <br /> BUILDING PERMIT APPG~T~ - <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL~ [ COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> <br /> ( ) Alteration ( ) Other ( ) Alteration <br /> ( ~)/Accessory ( ) Change of Occupancy <br /> <br />Energy Path: ~/~tL~ . No. Stoties / No. of Employees: Existing - <br /> <br /> MARION COUNTY <br /> ~IJILDIN(j iN,qpt:.OTiO <br /> Use Of'S~ctur~. <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br />New - <br /> <br /> ~.- ~..~ <br />Is this a historical building? Yes ~ <br /> <br /> No. Bedrooms: <br /> <br />Garage: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> /r <br /> <br /> Subdivision <br /> <br /> M°bile H°me Park ~/~; ~ b m ~/~~ <br /> ' Township <br /> Section ~,~0 ~.~ Range ~ ~,~ <br /> Lot Width //o~ Lot Depth /~ Acres <br /> <br />Mailing Address~ <br /> <br />: Phone No. ~q/__ <br /> <br />Lot Block <br /> <br />Space # / <br /> <br />Water Supply: <br />Private Well ( ) Spring <br />Community Well ( ) City <br /> <br />Zone /~/~ Map <br /> <br />Irreg. Lot ~e~ Corner y~ S <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 /> <br /> Mailing Address /r~ Phone <br /> <br />( lam an AUfq~IORIZED REPRESENTAT~f the ~o~rty owner or~ontractor. <br /> · ?Tar <br /> Mailing Address hone -- ~/~/ <br /> F eo, 07.- <br /> ( 'A ,/?- -, .-/? .~ · w/~. .... ; <br /> <br />4. FEE SCHEDULE <br /> <br />Ae <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 /> <br /> (3) Structural Plan Review (.65% x Al) ~t.~/~,g.~, 2 <br />· ' ' Review (.4°M16 x AI) <br /> <br /> (5) Zoning Surcharge, if applicable (.05% x A 1) = <br /> (6) Seismic Surcharge = <br /> <br />Lg./?/,,2 <br /> <br />q~.5d <br /> <br />6-08 <br /> <br />RECEIPT: <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />TOTAL <br /> <br />=$ <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 Pti ~/ ~~--~'~ ~. y~-.~/~/~-._ Phone: <br />Signature of Applicant: /..~/~7~/~_~__~ /. L.~~ ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />