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1FOR CITY VALIDATION <br /> Received [~y: t/]~ 4 ~-~ <br /> Zoning Vali~fion: Iff ~ <br /> Date: ff~q~ ~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church SL NE - Room 132 <br /> Salem, Oregon 97301 <br /> ~eat: /0 / <br /> <br /> FAX ~-794~ Ri~t Sid~:]~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> ) New <br />( ~dition ( )~l~afion ( )A~ifion ( <br /> <br />( )Altera~on ( )O~er ( )Alteration ( )Sign <br />( )Accesso~ ( )Ch~geof~cu~cy ( )~er <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />M~ileHomeP~k ~ S~ ~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (S~ "Valuation Schedule" to ~ valuation <br /> <br />on square footage of project) Valuation: $ <br />(I) Permit F~ <br /> <br />(2) 5% S~ Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review 665% x Al) <br /> <br />(5) ~ning Su~h~ge, if appllcable 605% <br /> <br />(6) Seis~e Su~ge <br /> <br />I hereby certify that the above information is corr~t. <br /> <br />Permits ar~ non-trans fermble and expire ff work is not star~ within 180 days of issuance Or if work is susl~n0~ for 180 days. <br />NameofApplicant(PleascPdnt): ~t'~__.~ ~ V~.~~ Phone'. <br />Signature of Applicant: .Dat~: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />=$ <br /> <br /> <br />