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.{FOR CITY ~ALIDA.TJg_N <br />'lRec~ived By: ..,~~ <br /> ° <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br />COMMUNITY DEVELOPMENT CENTER City Sethagk <br />285 Chumh St. NE - Room 132 <br /> Salem, Oregon 97301 Fmn~: ~ e/ )Pea): <br /> 8:00am-4:30pm Phone 58g-5147 <br /> ~4hr. lnspeetlonLine373-4427FAXS88.7948 ]Ld~Slde: ..~/ RightSidc:,~ / <br /> <br /> ONE & TWO FAMILY DWELLING PERMIT APPLICATION <br /> Includes electrical, mechanwal, plumbing fees / <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 ; ~,~ ~-~ ~'~ <br /> <br />1. JOB DESCRIPTION q~0~q il gU ;, <br /> Single Family Dwelling With Attached Cratag¢ <br /> ) New Single Family Dwelling With Detached Oaxage [~/~ [Yt 0 N COUNTY <br /> ) New Duplex , ,~ ~ i,-Dr <br /> 8UILD.,'~ INo, cCTION <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> } No. Stod~ ~.. Detached Garage Height: /,~ ~ <br />Balem~u: ~l. I Main Fl~or: ~ ~ { Second Floor:.~"~O [ ~arage: ~I~{~ <br /> <br />Other: <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) t am the PROPERTY OWNER and own, reside in, or will reside in thc comploted structure and will be my own general vontractor, I understand that I must register as a construction <br /> contractor if the sh~aure is sold or offered for sale bvfore or upon completion. If I hire subconm~ctors, I will hire only subconrn~ctors mgisto~i with the Co~sm~etion Contractors Board. <br /> <br /> Registration No. O_.~,,~.~;. IO0~[ <br /> <br />() <br /> <br />I am aa AIOTHOlilZI~r~ REPRESENTATIV~ of the property ownlr or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br /> TOTAL $.345 PER SQ FT <br />PLAN REVIEW FEE: /~./~) <br /> <br />B. PERMIT FEES <br />1. Permit Fee (A- 1) <br />2. State Surcharge (5% of A-l) <br /> Plan Review Fee (A-2) <br /> . <br /> lnv~stigetion Fcc ($1345 per <br /> <br /> Reiml~ztion F~ $25,00 <br /> <br />=$ <br /> <br />=$ <br /> <br />Dwelling labels must be obtained at Marion County Bnildfng Inspection and must be placed at the jobsite prior to inspection for plumbing, electrical and <br />mechanical work. Contact Marion County for instructions. <br /> <br />1 hereby certify that the above ~e'ormat~ is correcL Permits are nonrtransferrable and expire if work is not started within 180 days of issuance or if work is susp¢ndcd for <br />180 days, ~ , ) ( <br />NameofApplicant(~{'~-~L--- ~ ~ ~{---~ '~'~ Phone: Zi) ~ -- ~O~~ <br />SignatureofApplic~.n~Z .~,- ~ ~ - Da~e: .~' 2-~--~ <br /> <br /> <br />