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iF. OR'CITY VALIDATION I MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br />· Received By:.ell/~ (4/ COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 Eity Sethaek Rexlucmm~nt~: <br /> IZoning Validation: ~, ~ [ Salem, Oregon 97301 -- , . <br /> <br /> - [ 8:00nm-4:30pmPhoneS$8-$147 ~-ih~'~ ~~ IR~ar: I~¢'' <br /> 24hr. lnsgeetionLtne$88-7904 l~¢ll~ ~}.~dr [i1'1 IPa.htSld~. Ct <br /> BUILDINGPERMITAPPLICA'~tONjij~ 30 ]~}~}? ~ <br /> COMPLETE ALL SECTIONS. 1 THROUGH 4 <br /> <br /> 1. JOB DESCRn'TION MARION G00NT~ <br /> <br />RESIDENTIAL COMMERCIAL ~lJl LDI~f <br />(~Addifion ( )Relecation ( )Addition ( )New <br />( ) Almration ( ) Other ( ) Alteration ( ) Sign <br />( )Accessory ( )ChangeofOccupancy ( )Other <br /> <br />2~ LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) I am the PROPF~TY OWNER and own, reside in, or will reside in the completed stmcmm and will he my own general contractor. 1 understand that I mast register as a <br /> contractor if the structure is sold or offered for s~le before or upon completion. If I hire subcontractors, I will hke only subcontractors registered wi~h the Comtmctlcfl Contrac~w Bo~:L <br /> If I change my mind and do him a general contractor who is registered with the Constracfion Conh-actors Board, I will immediately notify Marion County of the name of tho <br /> <br />( ) I am a CONTRACTOR r~gistemd with the State of Oregon. <br /> <br />() <br /> <br /> Registration No. <br /> <br />I am an AUTHORIZED REPRESgNTATI¥g of thc inoger~y owner or contractor. ~1 <br /> <br />4. FEE SCHEDULE <br /> <br />on squm'e foo~ge of project.) ~(O~--~ <br />(1) P~rmit I:~ <br /> <br />B. Miscellaneous Fe~s <br /> <br /> (1) Additional Plan Re'ri~ws or Addendun~ <br /> (2) Investigation Fe~ <br /> (3) Reinspectlon Fe~ ~ $25.00 <br /> (4) Other lnspoctions not listed abow <br /> <br />RECEIPT: <br /> <br />=$ <br /> <br />TOTAL = $ <br /> <br />I hereby cer~fy that the above information is correct, <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />Name of Applicant (Please Prin0= H 0 ~.~l ~ ~/'~ W'~ q Phone: <br />Signature nf Applicant: ~-~ .~,_O~L,~ ~C.~.~d ~ ~~. ~. Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />