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IFOR CITY VALIDATION <br />Received By: ,~ ~ _~*~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <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 58~4~ <br /> 24 hr. Inspection Line 58~-~ ~F'~ ~ -- <br /> FAX588-7948 <br /> L Elt <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements:~.~ ~/ <br /> <br />~*Side./'-' I~Side: <br /> <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL I COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation [ ( ) Addition <br /> ( ) Alteration ( ) Other I ( ) Alteration <br /> <br />~Accessory A () Change of Occupancy <br />Energy Path: ~'~No. Stories [ No. of Employees: Existing - <br />Square Footage -Basement: Main Floor: Second Floor: <br /> <br />()Other / /~2 ~ <br /> Is ~is a histofic~ building? Yes -~ <br /> New - ~ No. B~ms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision ~ ~t <br /> <br />Section ~ Towns~p g~ Range ~ Zone ~ <br />~t Wid~ ~I ~t Dep~ /~ ~ I Acres I~g. ~t ~ <br /> <br />Pbo.e <br /> <br />Cross <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 general cona'actor 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 />am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />Valuation: $ <br /> <br />on square footage of project.) <br />(1) 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 /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />RECEIPT: <br /> <br />=$ <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 />Nme of Applicant (Please Print,: T_ _~r~.J ~ t'~'/~ Phone: <br />Signature of Applicant: ~~~~~. Date: ,~--,,~/ <br />MC 15-73 R~ <br /> <br /> <br />