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IFOR CITY VALIDATION <br />Received By: ~ <br />Zoning Validation: <br />IDate: 2-~9- <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> I <br /> 285 Church St. NE - Room 132 Ic.Front:ity Setb~ack RequirementS~v~).~_/~-' , <br /> Salem, Oregon 97301 ~-'', ~ <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 i' ~i~i ~/.~'~ ~'~.'~'~ht <br /> Side: <br /> FAX 588-7948 l~,~,!i~ .;.,~~~, ~~, x..~ <br /> BUILDING PERMIT APPLICATIO~ ~J <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br /> RESIDENTIAL COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> ( ) Alteration ( ) Other ( ) Alteration <br /> <br /> (v.')~ccessory ( ) Change of Occupancy <br />Description of W°rk ~~ 4 ~I ~f~, <br />Energy Path: No. Stories ~/t INo. of Employees: Existing - <br />Square Footage -Basement: Main Floor: Second Floor: <br /> <br />Use o~gr~Pthit~~. <br /> <br /> Is this a historical building? Yes <br />New - ] No. Bedrooms: <br /> ..~ 0 D ] Other: <br /> <br />Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mailing Address <br /> <br />Tax Acct. No. /~t <br /> <br />sp~tace # //2-. <br /> <br />Irreg. Lot ~ <br /> <br />Map <br /> <br />Comer <br /> <br />PhoneNo. 3 91- OTO, te <br /> <br />Cross Street <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring ((~ <br />Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION I 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 him 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 Namq, Registration No. <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Mailing Address ~0 ~ ~ Phone <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 /> <br />(3) Structural Plan Review (.65% x Al) ~,~ . = <br />~)-~rc, & Lif~ ~af~ty Fiiul ~.=vi~w (.4G% n .q <br /> <br /> (5) Zoning Surcharge, if applicable (.05% x A 1) = <br /> (6) Seismic Surcharge = <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 =$ g '~' 3¢ <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):c.~.~~.~~ & ~t~/~,~. ~k/~J',~ Phone: <br />Signature of Applicant: ~ Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />