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OR'CITY VALIDATION ] MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> ~.~,~ ~ ~ ,L COMMUNITY DEVELOPMENT CENTER <br /> ¢cived By: [.J~/'y ' 4' ~ ~,~r~ [zlL_ 285 Church St. NE- Room 132 {Cl~y Setba~k!~nt~: <br /> · ~, ~,v ~ I Salem, Oregon97301 <br /> mug Validation: "-~:~-~v'"-~/ 8:00am.4:30[~lphone585.514? <br /> · 24 hr. InaPeeflon I <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />1. JOB DESCRIPTION '- ...... ~ I <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile Home P~ S~ce ~ <br /> ~vamWell ( ) S~ng ( ) <br />~Wid~ ~ / ~tDepth ~ / Acres I~g. ~ Co~r ~W~l ( ) Ci~ ( ~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation Schedale" to d~nmine valuation baaed <br /> ,.5 <br /> <br />onsquarefootageofprojeet) ~ '~-~.n~Valuatio~:$ <br />(1) Pennlt Fee <br /> <br />(2) 5% Stale Surcharge (.05 x A I) . <br />(3) Structural Plan Review (.65% x Al) ~. ~ <br />(4) Fire & Life Safety Plan Review C40% x A I) .~' ~o <br />(6) Seismic Surcharge ~ [ <br /> <br />I hereby certify that the above information is correct. <br /> <br />Permits are non-transferrable and expire if work is not started within 150 days of issuance or if work is suspended for lgO days. <br /> <br />NameofApplicant(PleasePr;nt): ho e: ,57 3- <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />