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IFOR CITY VALIDATION' <br />Received By: <br />Zoning Validation <br /> <br />Date: , o2 -~/- 9 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( vq'~ccessory <br />Description of Work ~,~~L~O~t~ <br /> <br /> Footage -Basement: Main Floor: I Second Floor: <br />Square <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 City Setback Requirements: <br /> Salem, Oregg"~.... I -- <br /> 8:00am-4:30pm P]h~ ~.[~l~ ~'~ ¢'~ ~.~ _ Ivr°nt: <br /> 24 hr. Inspection/l~'e ~]~li~/~, 1I ! i:.~ ~ F",lJ~ft Side' ~- '/~l.~h'~',de. <br /> { 7/! <br /> <br /> ,~IflLDING .. OU, IT~ _ . ~ - <br /> COMMERCIAL INSp~ <br /> ( )Addition ( )New <br /> ( ) Alteration ( ) Sign /~ <br /> ( ) Ch~ge of Occupancy ( ) Other <br /> <br /> Is ~is a histofic~ buil~ng? Yes <br /> <br />New - [ No. Bedrooms: <br /> ./~ O ~ Other: Height: I ~.. ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Property Owner <br /> <br />Subdivision <br /> <br />Mailing Address <br /> <br />Tax Acct. ~o. <br /> <br />Lot <br /> <br /> Space # 1cMoa~ppm <br />IZone <br /> <br /> Irreg. Lot ~D er <br /> <br />Phone No. 3 <br /> <br />Cross Street <br /> <br />Block <br /> <br />Water Supply: <br />Private Wall ( ) Spring ( ) <br />Community Well ( ) City (.-9'''''~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />am thc 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 />contxactor 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 thc name of thc contractor. <br />am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Na[ne · Registration No. <br /> <br /> am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> MailingAddress ,,~/,af~A..dt~__~ Phone 7 t,.q.-7 '7 t.~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedule" to determine valuation based a. <br /> <br />on square footage of project.) Valuation: <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 /> <br />(6) Seismic Surcharge <br /> <br />RECE1PT: <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />=$ <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 />Name of Applicant (Please Print): ~4~ 0 {~/~'"J' Phone: <br />Signature of Applicant: ~d~:~/l~'~/-..-~/~.f/~ Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />