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FOR CITY VALIDATION <br />Received By: ~//~t/7} ~ <br />.Zoning Validation: t ff./ff~ <br />Date: $'q~ B-q b <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> ( ) Addition ( ) Relocation <br /> <br />( )~ration ( ) Other <br />(V') Accessory <br /> <br />MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br />COMMUNrrY DEVELOPMENT CENTER [city S~tback Reqnlr~m~ts: <br />285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 [Front: <br /> 8:00am'4:301nn24 hr.~8~,7904Ph°ne 588-5147 ILefl Side: <br /> <br /> [ co~¢m-~cu~.,._M,4RlON ,,~. :tO '.~ U=ofS~t,~: - ' <br /> <br /> ( ) Change of Occupancy ( ) Other! <br /> <br />/2- <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />Block <br /> <br />Wa~r Supply: <br />Private Well ( ) Spring ()~, <br />Community Well ( ) City <br /> <br />( ) I am the PROPERTY OWNER ami own, t~ide in, or will reside in the completed sUucture and will be my own general contractor. I understand that I must register as a construction <br />contractor if the structure is sold or offered fo~ sale before or upon completion, lfI ~ subcontractors, I will hire only subconUactors registered with the Construction Contractors Board. <br />If I change my mind and do hire a general conlnctor who is mgister~l with thc Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br />(,~ I am a CONTRACTOR registered with the State of Ol~gon. <br />Business Name Registration No. <br /> <br />4. FEE SCI-1F. DULE <br /> <br />A. <br /> =$ <br /> <br />VALUATION (See "Valuation ScbedulC to determine vnluation based <br />on squa~ fontage of project.) Valuation: $ ~t//~, <br /> <br /> (1) Permit Fee <br /> <br /> (2) 5% State Surcharge (.05 x Al) <br /> <br />--(3) 3uu~w,,.l Plan Review (.65% x Al) <br /> <br /> (5) Zoning Surcharge. if appUcable (.05% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee ~ $25.00 <br />RECEIPT: (4) O~ons not listed above <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 />Signature of Applicant~ Date: <br /> <br />?o'r~ :s 9.5'.q4 <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />