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IFOR CITY VALIDATION <br />Received By: L~__/~- ~ ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br />( ) Addition ( ) Relocation <br />( ) Alteration ( ) Oher <br />( ,~ccessory <br /> <br />Energy Path: ~ ~ ] No. of Employees: Existing - <br />Square Footage -BaSement: ] Main Hoot. ] Sccond Floor. <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> <br /> Salem,eg~t~f~ ~"~ ~-,b r.~ Ore t l <br /> <br /> ~OILDIN N~ <br /> <br /> ( ) A~don ( ) New / <br /> <br /> New - ~ No. B~: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision <br /> <br />Tax Acct No. <br /> <br />sp~# 4 / <br /> <br />Phone No. ~ <br /> <br />irreg. <br /> <br />Block <br /> <br />Water Supply: <br />l~ivm Well ( ) Spring <br />Community wen ( ) city <br /> <br />3. CONTRACTOR INFORMATION m PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />' ( ) I am the PROPERTY OWNER and own, reside in, or will ~eside in the completed slmcture and will be my own general conlracU~r. I understand that I must register as a construcfiun <br />conlracto~ ff the structure is sold or offered folr sale befor~ or upon compleliun, ff I ~ subconmwtors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a general cunmwtor who is ~gis~d with the Construction Contractors Board, I will immediately notify Ma/ion County of the name of the conUacWr. <br />· (.~ lamaCONTRACTOR~egisteredwi~h~eStateofOregon. <br /> Busincss Naine ~ ~.. / Regislrafion No. <br /> 7 / <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuafio~ Schedule" Io dete~nine valuation b~u~d <br /> <br />o~ square footage of pmj~t) Valuatiun: $ <br />(1) Pennit Fee <br />(2) 5% Stale Sm-charge (.05 x Al) = <br /> <br />(5) ~ S~, ~ a~E~le (.05% x Al) = <br />(6) ~c S~ = <br /> <br />w~sceuun¢ou, Ms <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> (4) O~h~ons not listed above <br /> <br /> I hereby certify that ~he above information is correct. <br />.Permits are non-transferrable and expire ff work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Appl/cant (Please ~/~J~ ~'~ /F/'g~j~3/U~/~'~--) ~ dZ~'~ Phone: <br />Signature of Applicant: ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />