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FOR CITY VALIDATION <br />.R~eived By: <br />Zoning Validttion: <br /> q <br /> <br />COMIULETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br />COMMUNITY DEVELOPmeNT CENq~ER <br /> <br /> Salem Oregon 973.01 <br /> <br /> BUILDING PERMIT APPLIC~A~ION~o,,~,?Q/f/ N <br /> <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL COMMERCIAL ' {mcmre: <br /> ( ) Addition ( ) R~location ( ) Addition ( ) New <br /> ( )Alteration ( )Other ( )Alteration ( )Sign <br /> (~ccessory ( ) Chang~ of Occupancy ( ) Other <br /> <br />Square Footage -Basement: I <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 and own, rcskl¢ in, or will reside in the completed sm~ctmc and will bc my own general contxactor. I undezstand ~ha~ I must register as a cons~uction <br /> contrac~r ff thc structure is sold or offered for sale before or upon completion. If I ~ sulx:omractom, I will hire ovly subcontractors register~l with the Cons~ucfion Contractors Board. <br /> ff I cha~ge my mind a~d do him a general contractor who is registered with thc Conmu~ on Contxactors Board, I will imm~llat~ly notify Marion County of the name of the contractor. <br />(~ I am a CONTRACTOR regismred vAth the State of Oregon. <br /> <br /> (~)~ I am an AUTHORIZED REPRESENTATIVE of the property owner or contxactor. <br /> <br />4. FEE SCHEDULE <br /> <br />(1) Permit Fcc <br />(2) 5% 5~ate Sumharge (.05 x Al) <br />(3) S~mco~al Plan Review (.65% x Al) -- = <br /> <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />~, q3 <br /> <br />RECEIPT: (4' 97~'e~°n$ n°t listed ab°Ye <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits ale non-transferrable and expire if work is not staved within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Print): ~ ~ t~ ~'4'/:~° Phone: <br />. , <br />SignatumofApplicant: "~ ~/C]',~'x,,C.,,~...~ Date: <br /> <br />MC 15-73 Rev 1i95 <br /> <br /> <br />