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IF. OR CITY V/V/V~.LIOATION <br />Received By: ~ "~ ~.~,~'~ <br />Zoning Validation:. <br />Date' ~-,~ O-t~ <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 /> Rear: I0 ~ <br /> Right Side: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation I ( ) Addition <br /> ( ) A~lion ( ) Other I ( ) Alteration <br /> ( t~,~t~cessory [ ( ) Change of Occupancy <br /> <br />Energy Path: I No. Stories t [ No. of Employees: Existing - <br />Square Footage -Basement: [ Main Floor: ] Second Floor: <br /> <br />( ) Sign <br /> <br />( ) Other <br /> <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588-5147 Front: <br /> 24 hr. Inspection Line ~ ~ 'i ~71 ) ~ q5~I ~ ~ a.~ ~ <br /> <br />BULLDOG PE~IT A~~TION <br /> <br /> /~ ~ J ~ ~ ~g.R!(%! O01JNTY <br /> <br />New - <br /> <br />Is this a historical building? Yes - ~ <br /> <br />Garage: <br /> <br />Tax Acct. No. <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />,ob '92// <br /> <br />No. Bedrooms: <br /> <br />Phone No. <br /> <br />Cross Street <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring <br />Community Well ( ) City <br /> <br />Subdivision Lot <br />Mobile Home Park/~ ~~ ~.,~,.,~.--~__~...,/"}0'~ , /~d~fl- ~.~ Space # <br /> <br />~t Wid~ ~5 ' I ~t ~p~ I Acres I~eg. ~t <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 thc 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. q [d9%~% <br />Mailing Address Phone <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />hng Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: <br />(1) Permit Fee <br />(2) 5% State Sumh~ge (.05 x Al) <br />(3) S~cmrfl PI~ Review (.65% x al) <br />(4) Fire & Life S~ety PI~ Review (.40% x Al) <br />(5) ~ffing Sureh~ge, if applicable (.05% x Al) <br />(6) Seis~c Surch~ge <br /> <br />RECEIPT: <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />TOTAL <br /> <br />=$ <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 />Name ofApplicant(PleasePrint,: _~A~ ~O~/"~/--~/. Phone: <br />Signature of Applicant:~ff~~ ~ ~/~~ ~~--~ <br /> Date: <br />MC 15-73 Rev 1/95// <br /> <br /> <br />