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zR~oeOk--~ITY VALIDATIONI MARION COUNTY BUILDING INSPECTION <br /> ~/, ~// .... ' ~/~ COMMUNITY DEVELOPMENTCENTER <br /> ceived By: ' ~ ] t,~,'t~.o~r.J,.~ 28~ Church St. NE - Room 132 <br /> <br /> · .. / ~ { Salem, Oregon 97301 <br /> nmg Vallda~on: ~_ ~ I 8:00~m-4:~0pm Phone 5~-5147 ~ <br />[Date: to 2~ /~, I ~4 lat. lmp~cflon Line S88-7904 <br />/ { ~ ~ FAX $~8-7~48 <br /> <br /> BUILDING PERMIT APPLICATION <br />co rE ^LL S CT ONS,, ROUOH 0¢ ? 3 <br />1. JOB DESCRIPTION <br /> <br />( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br />( ) Accessory ( ) Change of Occupancy ( ) Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~v~ weft <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> N'am~t~ ~ <br /> Mailing Ad&~ ss ~ ~ ~ <br /> <br />4. FEE SCHEDULE <br /> <br />on r4qmre footage of project.) <br />( 1 ) Permit Fee <br /> <br />(2) 5% State Surcharge LOS x Al) <br /> <br />TOTAL <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transfen'able and expire if work is n~ started within 180 days of issuance or if work is suspended for 180 days, <br /> <br />Name of Applicant (Please Print): /~/ ~*~C ~.~ ~ Phone: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />