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FOR CITY <br />Received By: <br />Zoning Val!dation: ' <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 /> BUILDING PERMIT APPLICATION <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Left Side:~~ht Side: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION ~i~,~;~:a q~.y r(~)~ ~ ~ <br />Addition ( ) Relocation ( ) Addition F E ~ ~ ~( ~ i'Use of S~c~e: <br />Alteration ( ) O~er ( ) Alteration MARION 60~Y /~ g~C ~ <br />(~cesso~ ( )Change of~fNG INBP~T~ON <br />~scfipfion ofWor~~2 / ~ ~ ~ '~ ~ ~ I Is ~is a historic, buil~ng? Yes - ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Su~ivision ~t <br />MobileaomeP~k ~/~~~ ~~ ~ ~ ~ Space~ <br />S~fion ~ TownsMp ~ ~ge ~ ~ne ~ <br />~t Wid* ~ Lot Dep* / ~ ~ Acres I~g. ~t ~ <br /> <br />Tax Acct. No. ~/~ff ~/~ff ,~3~/ <br /> <br />Phone No. <br /> <br />Cross Street <br /> <br />7?7- <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 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 />Maflia~ ss <br />( ) I am an AlYrItORIZ REPRESENTATIVE of the property owner or contractor. <br /> <br /> Mailing Address ~_~ ~ ~. Phone <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(43 .~,~ .~ L;£~ 3,,.%:.~ I'll, K,~k:w (.40~ <br /> <br />(5) Zoning Surcharge, if applicable (.05% <br /> <br />(6) Seismic Surcharge <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />=$ <br /> <br />TOTAL :$ L~-2'~/ <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): ~ ~'~ ~:~'~/~'d'~./~ ~ ~.~./ ~ Phone: <br />Signature of Applicant: ,~ c..~c..-~--..._.~ ~ -~,..,,,..,.,,--~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />