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F~R CITY VALIDATION <br />Zoning Validation: (/ t/~.... <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELCfPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> $:00~m-4:30pm Phone $~-g!47 <br /> 24 hr. Inspection Line ~85.7904 <br /> FAX $88-794~ <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH <br /> <br />1. JOB DESCRIPTION <br /> <br /> v, gSlV~'n~ CO~RCt~ ' < CT/t <br /> (~dditlon ( )Rel~afioo ( )AddiSon ( )New <br /> ( )Alteration ( )O~er ( )Alteration ( )Sign <br /> ( )A~sso~ ( )ChangeofOceupancy ( )Other <br /> <br />Energy Pa~: [ No. Sto~~ No, of Employes: Existing - N~w - ~ No. B~: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) 1 am the PROPERTY OWNER and own, mfide in, or will reside in the completed s.ucmre and will be my own general ¢onuactor. I under, md g~at I must register as a construction <br /> conlractor if the stmctore is sold or offered for sale before or upon completion. If I hire subcontractors. I will hire only subcontractors reghtered with the Con~Uuction Contractors Board. <br /> If I change my mind and do hire a general con~ractor who is registered wi~ the Construction Contractors Board. I will mimedi~tely notify Marion County of the name of the con.actor. <br /> (~ [ am a CONTRACTOR reglste~ed with the grate of Oregon. <br /> Business Namq, <br /> <br /> (~ I am an AUTHORIZED ~EPRESENTATFVE of the property owner Or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />An <br /> <br />VALUATION (See "Valuation Schedule" to d~tormino valuation bas~ <br />on squal~ footage of project.) Valuation: $ *"~. ~ <br /> <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Structural Plan Review (,65% x AI)~ ~-~- ~. <br /> <br />(3) Zoning Surcharge, if applicable (.05% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />(2) Investigation Fee <br /> <br />(3) Reinspectim~ Fee @ $25.00 <br /> <br />I hereby certify that the above information is con~t. <br />Permits are non-transferrable and expire if work is not statled within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applieant (Please Print): tJ~_, ~) ~t/:~ Phone:¢.~"O_.~_C~////~,./q <br />MC 15-73 Rev 1/95 <br /> <br /> <br />