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FOR CITY VALIDATION] MARION COUNTY BUILDING INSPECTION ~ ~/~ ! ITY D CENTER Received By? ~-~'~ [ _ , ?hutch Zoning Validation: ~ ~ ~ Salem Date: q-~-~Ca ! o ~ ,~O/ Right COMPLE?E ALL SECTIONS, 1 THROUGH 41. JOB DESCRIPTION RESIDENTIAL COMMERCIAL ~/ /f~dso of Structure: (¥~ddition ( ) Relocation ( ) Addition ( ) New ( ) Alteration ( ) Other ( ) Alteration ( ) Sign ( )Acc. esso, ( )ChangeofOccupancy ( )Other Descdpd°n°fW°r~O~l'l"l~ '~tr~ P_.Y..I'~'TIIq. C~I 4"~L,~ I:~LIII.,~IMh I I~thl~ah~todcalbuild~¢ 2. LOCATION OF INSTALLATION 97 z5 Mobile Home ~k Space ~ S~on 3 ~ Township ~ Rang~ ~W ~ ~ Map Wa.rSuppl~: ~v~We~ ( ) S~ng ( ) 3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK ( ) I am the PROPERTY OWNER and own, reside ~. or will reside in th~ comple~d structure and will b~ my own general contractor. I und~atand thai I must r~gist*r ~ a eons~ucilon contractor if the structure ia sold or offered for sate before or upon complaiion. If I hi~ subconuactors, I will hire only mbcontracwrs t'~gism~:[ with th~ Con~tmcilon Coatractova Board. If I change my mind and do hire a g~neral conh-actor who is registered with the Construction Contractors Board, I will immediamly notify Mati~n County of tde tame of the contractor. ( ) I am a CONTRACTOR registered wilh the State of Oregon. ( ) Name Mailing Address 4. FEE SCHEDULE A. VALUATION (See "Valuation Schedule" to determine valuation based on square footage of project.) Valuaiion: $ /~! (1) Permit Fee (2) 5% State Surcharge (.05 x Al) ~?o, "L~ n~/~~'O~= _ . (3) Structural Plan Review (.66% x A 1 ) = (4) Fire & Life Safety Plan Review (.40% x Al) = O TOTAL =$, I hereby certify that the above information is eorcect. Permits am non-transferrable and expire if work is not sta~ed within 180 days of issuance or if work is suspended for 180 days. NameofApplicant(PleasePdnt): /~t~/~--~ ~. ~.~"/~"~//" Phone: MC 15-73 Revl'n)' // - 0 .... Ef¢5.