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FOR CITY VALIDATION' <br />Rqceived By: ~ <br />Zoning Validation: <br /> <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line b~-~tS~]~/'~ <br /> <br /> BUILDING PERMIT Affn~'ATION -- <br /> <br />RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> j~ Accessory <br />Description of Work <br /> <br />Energy Path: l~[ No' <br /> Stories <br /> <br /> -Basement: [ Main Floor: <br />Square <br /> Footage <br /> <br />COMMERCIAL ~ ·~r~ <br />( )Addition (B~[,~lN~ <br />( ) Alteration ( ) Sign <br />( ) Change of Occupancy ( ) Other <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requ~ements: <br /> <br />I ~54d~cture: <br /> <br /> Is this a historical building? Yes -(~o~ <br /> <br />No. Employees: Existing - - <br /> of <br /> New <br /> <br />I Second Floor: <br /> <br />2. LOCATION OF IN~S/TAL~TION <br /> Property Owner Cff~d~/ ~-. L Mailing Address <br /> <br /> Su~ivision <br /> <br />Township <br /> <br />Range <br /> <br />Lot Depth /o2(' · Acres <br /> <br />Mobile Home Park <br />Section~,~O <br /> <br />No. Bedrooms: <br /> <br />{Height: <br /> <br />P honeNo. <br /> <br />Cross Street <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, aside 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 />Mailing Address Phone <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Maihng .~ddres . ' ~ ~ <br />- / /. f Phone <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ ~.~.~1/~. <br /> <br />(1) Permit Fee ~./t/, ~%"-O <br />(2) 5% State Sumharge (.05 x Al) = ~' '~ ~ <br />(3) Structural Plan Review (.65% x A 1) __ = ~ ~ <br /> <br />(5) Zo~ng Sumh~ge, if applicable (.05% x A 1 ) = <br />(6) Seis~c Sumh~ge = <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspoction Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br />~CElVr: q~ // <br /> <br />=$ <br /> <br />TOTAL =$ <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 />MC 15-73 Rev 1/95 <br /> <br />Phone: <br /> <br />Date: <br /> <br /> <br />