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[FOR CITY VALIDATION <br /> <br />Izoning Validation: <br />IDate: /- o2. o~. -~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( ) Accessory <br /> <br />Energy' Path: [ No. Stories ~' g" [ No. of Employees: Existing - <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, Oregon 97301 <br /> 24 hr' II~~~ 5~ <br /> BUILDING PE~['PPLICATIO~ne <br /> <br /> COMM~C~ B~ILBI~ <br /> ()Addition ()New <br /> ( ) Alteration ( ~gn <br /> ( ) Change of Occupancy ( ) Other <br /> <br />Is this a historical building? Yes - No <br /> <br />LOCATiOS INs gos <br /> <br />Subdivision <br /> <br />Mobile Home Park <br /> <br />Lot Width ~100 I Lot Depth 1OO Acres <br /> <br />New - [ No. Bedrooms: <br /> <br />Garage: <br /> <br />Tax Acct. No.~~- <br /> <br />Space # <br /> <br />IMap <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring ( ) <br />Community Wen ( ) city ( ) <br /> <br />3. CON'I~tACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ~"fI am the PROPERTY OWNER and own, reside in, or will reside in the completed sUuctme and will be my own general conWac~. I understand that I must register as a construction <br /> contractor if the stmctore is sold or offered for sale before or upon completion, ff I hire subcontractors, I will hire only subeon~ac'a)rs o~istered with the Construction Contractors Board. <br /> If I change my mind and do hire a general contractor who is registered with the ConsUnefion Contractors Board, I will immediately notify Marion County of the name of the contractor. <br /> <br /> ( ) I am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Name Regislration No. <br /> <br /> Mailing Address Phune <br /> <br /> ( ) I am an AUTHORIZF~ REPRESENTATIVE of lhe property owner or conWactor. <br /> Name <br /> <br /> Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square foo~ge of project) Valuation: $ <br /> <br />( 1 ) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Slmctoral Plan Review (.65% x Al) <br /> <br />($) Zoning Sorcharg~, if ~q~pllc,~ble (.0~ x Al) <br /> <br />(~) Seismic Sorchasge <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other lmspecfions not listed above <br /> <br />=$ <br /> <br />I hereby ce~ify 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 <br /> <br />Signature of Applicant: <br /> <br />! <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />