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FOR CITY VALIDATION MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY I <br /> · -~ ~'~'~ --7 COMMUNITy DEVELOPMENT CENTER I <br />Received By: ~;,a- ] ~{¢tx.~¢~-~ 285 Church St. NE - Room 132 Icity $~a~k I~luimn~nts: <br /> <br /> · . . ~/~¢ .,d'¢/)~ Sa~m. Or~gn. 9730~ Ce. I , <br />ZonmgV?datton: - /°ir S:00am-n:~0pmPhoneSaa-.~i~}~"~("~;~C-...-a,.. IF~'t: <br /> · ~4¢9 ¢7 _g.~ :M hr. Insgeet on Line $~- tv-v,--a~ .... . <br /> <br /> BUILDING PERMIT APP~']I;~N <br />COMPLETE ALL SECTIONS 1 THROUGH 4 ~ <br /> <br /> RESIDENTIAL COMMERCIAL <br /> (~dition ( )Relocation ( )Addition ( )New <br />( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br />( )Accessory ( )ChangeofOccupancy ( )Other <br /> quam F otage -B aaement: I Main FlooE <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, reside ia, or will r~alde in the completed structure and will be my own general conltacmr. I understand that 1 must register as a consR~etion <br />contractor if ~= stmctam is sold or offered for sale before or upon completion. If I hire subcontractors, I will him only subeonuactor~ regi~en~t with th= Consa'uctio~ Contmcw~ Boaxd. <br />ff I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I wilt immediately notify Maric¢~ County of tbe name of th~ contractor, <br /> <br />I am a CONTRACTOR registered with th~ State of Oregon. <br /> <br /> Business Name · ~ <br /> <br />I am an AUTHOR1ZED/REPRESF2NTATIVE of the pm~rty owner or contractor. - <br /> <br />Mailing Address <br /> <br />4. FEE SCHEDULE <br /> <br />An <br /> <br />VALUATION (bee "Valuation Schedule" to determine valuation based <br /> <br />on square footage of p~jeet.) Valuation: $ ~ <br />(ti ~e..i~ p~ ,Ct/. ,frO <br />(2) 5% State Surcharge (.05 x Al) <br />(3) st~¢~al e~ Ee~iew (.6~% x At) ~9-~. q_~ <br /> <br />(5) Zoning Su~hargc, if applicable (.05% x A I) <br /> <br />(6) Seismic Sumhm'gc <br /> <br />B. Miscellaneous Fe~s <br /> (1) Additional Plan R~vi~ws or Addenduma <br /> (2) Investigation Fcc <br /> (3) Eeins~fion <br /> <br />RECEII~f: <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 />S~gnatum of Applicant: ~ Dat~: <br /> <br />MC 15-73 Rev 1195 <br /> <br />=$ <br /> <br />'7'la ¢ -7 7 ,,.~..tf: <br /> <br /> <br />