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FOR CITY VALIDATION Received B~: ~b Zoni'ng Validation: ~ Date: ~',,~ / ~ ~' MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St. NE - Room 132 Salem, Oregon 97301 8:00am-4:30pm Phone 588-5147 FOR CITY USE ONLY City Setback Requirements: ti~ 24 hr. Inspection Lin~'l~ ILeft Si~l~"'J'/- ~ 1 Right Side: FAX 588'7~1~J]i.:~ ~c~_ ~ ~ ~ I '~' ~ COMPLETEi. JOB DESCRIPTIoNALL SECTIONS, l THROUGH4 q (.0' 0 I I q~/ -'"' ,~-~ 27 RESIDENTIAL I COMMERCIAL IVIlqRlOt~ Al Use of Structure: ( )Addition ( )Relocation ()Addition ~UIL~N~t~t~,~/..-L~ii~/.- ( ) Alteration ( ) Other I ( ) Alteration ( ) Sign ~[Kb"I~0e~ ~'- ,,.-. ,C cces$o y / I ( )CbangeofOccu ancy ( )Other Descripfiono~ f Work f~'"~/~9'~'/~' ~.,~.~~ Is this ahistoficalbuilding? Yes -~.,~ ~nergy Path: ~ F [ ~o. Stories ] No. of ~mployee~: ~xisting - New- No. B~oom~: 2. LOCATION OF INSTALLATION .~j~ff~ .f~/,~:~ ~ Tax Acct. No. ~"~. Lot Section ~ I-Township ~..~ Range ~ ~ne ~ -- ~ap ~id~ ~' ,/ ~t~p~ /~' Acres ] I~g. Lot W~ Comer 3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK Block Water Supply: Private Well ( ) Community Well ( ) Spring City / ( ) 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 contractor if the structure is sold or offered for sale before or upon completion. If I him subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. 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. ( ) I am a CONTRACTOR registered with the State of Oregon. Business Name Registration No. Mailing Address Phone (/ [ am an AUTHORIZED RE_PRESENT)~.eT~¥E of the property owner or contractor- 4. FEE SCHEDULE A. VALUATION (Sec "Valuation Schedule" to determine valuation based on square footage of project.) (1) Permit Fee (2) 5% State Surcharge (.05 x Al) = (3) Structural Plan Review (.65% x Al) ~ = (5) Zoning Surcharge, if applicable (.05% x Al) (6) Seismic Surcharge = Valuation: $ B. Miscellaneous Fees (1) Additional Plan Reviews or Addendums (2) Investigation Fee (3) Reinspection Fee @ $25.00 RECEIFr: (4)~2r3sTti°ns n°t listed ab°ve =$ I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. Name of Applicant (Please Print): ~/~,d_) /f~'~ - Phone: ~"~ Signature of Applicant: ~~--~ ~~ Date: R-- x~''~~ '" ~ .~ MC 15-73