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FOR GI,TY VALIDATION <br />Received B~: ~ <br />Zoning Validation: <br /> <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am4:3Opm Phone 5885147 <br /> <br />BUILDING PERM ICATION- ~ . <br /> <br /> RESIDENTIAL COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> ( )~ration ( )O~er ( )Alteration <br /> ( s4 Accessory ( ) Change of Occupancy <br /> <br />Square Footage -Basement: I Main Floor:. Second Floor:. <br /> I <br /> <br />BUlleD~iNSJ <br /> <br />( ) Sign <br /> <br />FOR CiTY USE ONLY <br /> <br />( ) Other <br /> <br />City Setback Requirements: <br /> <br /> eft Side: ~[~ Right Side: <br /> <br />U J~of Structure: <br /> <br />Is this a historical building? Yes - ~ <br /> <br />New - [ No. Bedrooms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision <br /> <br />s~.o. ~ <br /> <br />~o,,~ip ~S <br />L~ 133 A~ <br /> <br />Lot <br /> <br />]Iviniling Address ~ <br /> <br />Block <br /> <br />Space# <br /> <br />Irreg. Lot <br /> <br />Waler Supply: <br />PrivateWeH ( ) Sp~ing ( ) ~. <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 subcontracWrs, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire n 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 ~ CONTRACTOR registered with tbe Stato of Oregon. <br /> <br /> Business Ntme Registration No. <br /> a._3 / pt,, -/7 / / <br />( ) I am an AlfrHOR]ZED REPRF~ENTATIVE of the propewj owner or contractor. <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation. Schedule" to determine valuation based <br /> <br />on square footage of pmjeet.) Valuation: $ <br />(1) Permit Fee <br />(2) S% State Sureharge (.OS x Al) = <br />(3) 8tructural Plan Review (.65% x Al) = <br /> <br />(5) Zoning Surcharge, if applicable (.05% x A 1 ) <br />(6) Seismic Surcharge = <br /> <br />~sceuaneon~ ~ (1) Additional Plan Reviews or Addandums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspecfion Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> 781-~ <br /> <br />=$ <br /> <br />wrAL :s qS. <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not staffed within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name or Applicant (Please ~,,~:~ :~-'/--' ~ ! ~.~ Phone: <br />Signature of Applicant: ~' ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />