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MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> · COMMUNITY DEVELOPMENT CENTER <br /> Received B~: 285 Church St. NE - Room 132 Sity Setback R~lulrements: <br /> Salem, On~gon 97301 ~ ~"~ <br /> Validation: 8 00am-4 30pm Phone $_.~-.~1~7~ f..~ ~ ~ ~ <br /> <br /> BUmDmG PERMIT AI~p~IUATION ,~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 ~ .1 !,! ~ 1 b <br />1. JOB DESCRIPTION MARION 00[INLY <br /> <br /> RESIDENTIAL COMMERCIAL BUll. DIN <br /> ( )Addition ( )Relocation ( )Addition ( )New <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> (~Acce~sory ( ) Change nfOccupancy ( ) Other <br />DescripdanofWork~..t.4~~ ~ ~ ~ /,,~'g:,~'' I Isfl~isahistoficalbuilding? Yes - No <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am the PROPERTY OWNER ami own, reside in. or will reside in the completed st~ctur~ and will be my own general eonw~tor. I understand that I must register as a construction <br /> <br /> () <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />=$ <br /> <br />I hereby ce~ify that die above information is correct. <br />Permits am non-~nsferrable and expire ff wink is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applican, (Please Print): .~1 ,p.. /2c.~ ~.4// Phone: <br />Signature of Applicant: ~/~. Z .Z/~c,'~_ Dat~: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />