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FOR CITY VALIDATION MARION COUNTY BUILDING INSPECTION <br /> <br />Ree¢ivcd BY: ~ '~ ~.~ COMMUNITY DEVFi. OPMENT CEN'r~ <br /> 285 Church St. NE - Room 132 <br />Zoning Validation: ffff-~ <br /> <br />1. JOB DESCRH'TION <br /> <br /> RESID~ <br /> ( ) Addition ( ) RelOcation <br /> ( ) Alteration ( ) Other <br /> °- <br /> ono, <br /> <br /> Footage -Basement: [ Main Floor:. <br /> I <br /> <br />No. of Employees: Existing - New - <br /> <br />Second Floor:. I Garage: <br /> <br /> FOR CITY USE ONLY <br />City Setbnck Requirements: <br /> <br />Front: /~ ' ~ / <br />Left Side: Right Side: <br /> <br /> No. Bedrooms: <br />I °~e': ~_~OO I"eight:/Z? <br /> <br />t~Wiath .~',5' ~ Lot ~ //~, · ^~" I ~-g. Lot Come~ <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 undemtand that I must register as a construction <br />contractor ff the mucture is sold or offered for sale before or upon completion. If I hire subeonlractora, I will hire only subcontractors registered with the Construction Contractors Board. <br />ff I change my mind and do hire a gene~d contractor who is mgistored with the Construction ConU'acto~s Board, I will immediately notify Marion County of the name of the conlractor. <br />~J'~l am a CONTRACTOR registered with the S~qte of Oregon. <br /> BnsinesroName/% ~ Registration No, <br /> <br />-l~t~iling A ' Phone <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or conWactor. <br />Name <br />Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br />on ~.~,oouge or~o~t.) Val~on: S .~--~/~' <br /> <br />(1) l~rmit Fee <br /> <br />(2) 5% State Surchnrge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> · ;~. e.. ...... o ....... ( ~- r ~!.~/~J~ ~.,,, <br />(5) Zoning Surcharge, if applicnble (.05% x Al) <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 =$ ~t~o 5~ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-lransferrable 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 Prin~:'~~ J <br />Signature of Applicant: J~~'~~~ ZZ_~ <br />MC <br /> 15-73 <br /> Rev <br /> <br />Date: <br /> <br /> <br />