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R CITY V~LIDA,TSO/N <br /> ~d By: ' <br /> <br /> ng Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPM~qT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, O~gon 97301 <br /> 8:00am-4:~Opm Pho~ $88.$147 <br /> 24 hr. lmp~ctlan Line $85.7904 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br />( v~ddition ( )Relocation <br />( )Alteration ( }Other <br />( ) Accessory <br /> <br />De~crlpfion of Work <br /> <br /> FAX 5~-~1,~. ~ ~ <br /> <br />COMMERCIAL <br /> ( )^aaiUO~vlAR~ON COUN~Y)N~ <br /> ( )Ahe~[D~IG !NSPEC[I~. <br /> ( ) C~ge of ~cu~y ( ) ~ <br /> <br /> FOR CITY USE ONLY <br />CiO/Setback Requi~ments: <br /> <br />Un of Structure: <br /> <br />~n~gy Palb: I No. St~es ] No. of Employeez: Existlng - New- <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~v~Well ( ) S~ng ( )~ <br /> <br />3, CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) <br /> <br />4. FEE SCHR. I~ULE <br /> <br />7/. z¥ <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not s~arted within 180 days of issuafice or if ~ is suspended for 180 days. <br /> <br />Name of Applicant (PI ~ ~ ~o Phone: <br />Signature of Applicant: ~_~ Da~: <br />MC 15-73 Rev 1/95 <br /> <br />7bq~/P~ <br /> <br /> <br />