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FOR CITY VALIDATION <br />ReCeived By: ~ ~_~ <br />Zoning Validation: <br /> <br />Date' <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION I ?OR CITY USE ONLY <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 Setback Requirements: <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Pho~'l~ r ~.~ IFr°nt~ ~0~ <br /> 24 hr. Inspection LiL~]~t~ <br /> <br /> BUILDING PERMIT~7'~CATION <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( ) Accessory <br /> <br />COMM~,I~CIAL ~U I LD I ~I ~ <br /> Addition ( ) New <br /> (~Alteration ( ) Sign <br /> Change of Occupancy ( ) Other <br /> <br />Description of Work <br /> <br />Is this a historical building? Yes - ~ <br /> <br />Energy Path: ~'/ ,,c~. <br /> c.~'~ ~ No. Stories <br /> <br />Square Footage-Basement: ~ Main Floor: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />No. of Employees: Existing <br /> <br />New- ~, [ No. Bedrooms: <br />I Garage: ~',,,~ O Other: ~- <br /> <br />Second Floor: <br /> <br />Height: ~ i · <br /> <br />Property Owner U o ]n .,,.i '-~ tn rl , '~r'~ O.'n <br /> <br />Mailing Address <br /> <br />Tax Acct. No. q02~1-3oo <br /> <br />Subdivision <br />Mobile Home Park Space # <br />Section Township Range Zone <br /> <br />Acres <br /> <br />Lot Width <br /> <br />Lot Depth q3' <br /> <br />Lot <br /> <br />Irreg. Lot <br /> <br />Map JOo$ <br /> <br />Comer <br /> <br />Cross Street ~./t.~t ~ 2 ~-, <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 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 subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a 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 a CONTRACTOR registered with the State of Oregon. <br />Business Name Registration No. <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. ~:~'- P'/'"'~' ~,~ ,/ ~ <br />Name <br />Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br /> A. VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br /> on square footage of project.) Valuation: <br /> (1) Permit Fee <br /> <br /> (2) 5% Sm~ Surch~ge (.05 x Al) <br />~3(3) S~cmral PI~ Review (.65% x Al) <br /> (4) Fi~ & Life Sffety Plan Review (.40% x Al) <br /> (5) Zoning Surch~ge, if applicable (.05% x Al) <br /> (6) Seis~c Sumh~ge <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums = $ <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> <br />RECEIPT: (4) Other Inspections 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 />Name of Applicant (Please Print): O -.'"f-,/ Phone: <br /> <br />Signature of Applicant: Date: <br />MC 15-73 Rev 1/95 ~ <br /> <br />- <br /> <br /> <br />