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FOR,CITY VALIDATION <br />!~eceiv~d By: <br /> <br />'Zoning Validation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Front: I Rear: <br />Left Side: ] Right Side: <br /> <br />BUILDING PERMIT APPLICATION~b ~ ~(~ ~.~ ~"~i~ <br /> <br />RESIDENT/AL <br />('~5/Addifion ( ) Relocation <br />( ) Alteration ( ) Other <br />( ) Accessory <br /> <br />~scriptiun of Wore ('O/a,r~uc'r .... <br /> <br />Energy Path: I No. Stories <br />Square Footage -Basement: I Main Floor: <br /> <br />COMMERCIAL <br /> <br /> ( )Addition ( )New <br /> ( ) Alteration ( ) Sign <br /> ( ) Change of Occupancy ( ) Other <br /> <br />Is this a historical building? Yes - (~) <br /> <br />INo. of Employees: Existing - New - [ No. Bedrooms: <br /> I Second Floor: I Ga~ ge: ~l~l~ll~ J Other: / v'X 2/ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Property Owner <br /> <br />Subdivision &~6"/~/ /'t[faqt~0W$ ~ <br />' Mobile Home Park ~-/-e~ /~vl&'ltv~a/'a/4 <br />]Section 33 ' } Township ,~,~ I Range <br />Lot Width ~--,- ~0 ~~ { LotDepth ~4'ff'~ { Acres <br /> <br /> Space # <br /> <br />lrreg. Lot t~ - Coroer ~ <br /> <br />'Cross <br /> <br />Block <br /> <br />Water Supply: <br />PrivateWeil ( ) 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, ff 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 /> <br /> ( ) I am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Name Registration No. <br /> <br /> Mailing Address Phone <br /> <br /> ( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> Name <br /> <br /> Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br />A. B. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ ~. <br />( 1 ) Permit F~e <br />(2) 5% Stat~ Surcharge (.05 x Al) = <br />(3) Structural Plan Review (.65% x Al) = <br />(4) Fire & Life Safety Plan Review (.40% x Al) = <br />(5) Zoning Surcharge, if applicable (.05% x A 1 ) = <br />(6) SeismJ~ Sumharge = <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br />=$ <br /> <br /> RECEIPT: (4) Other Inspections not listed above TOTAL <br /> c a~s v/red <br /> 2D~¢¢z/'oa ~.~,'..~,¢,~ <br /> <br />I hereby certify that the above information is correct. ,.~7~ "~ ~ <br />Permits arc non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended~or'~O'"~ys. <br /> <br />Name of Applicant (Please Print): Phone: <br />Signature of Applicant: . Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />