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fOR CITY VALIDATION <br />eived By: f~ ~ <br />ning. Validation: -~___~_~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Pho~:~l~'~ <br /> 24 hr. Inspection <br /> ~AX sss.,~l~ ~'---- "~ ~1 <br /> BUILI~ING PERMIT ~'L~-b~y <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />~}ide: ~ I Risht Side: 5 <br /> <br />1. JOB DESCRIPTION <br /> <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> <br /> ( ) Accessory ( ) Change of Occupancy ( ) Other <br /> <br />DesclipfionofWork IstMsahlstodczlbuilding? Yes - No <br />SquareFootage-Basemen,: ]MainFhior: Is~°~dn°°r: ~._l~axage:.,,~ ~'~1~9~_/{~ O~ [ [Height: <br /> <br />JobAddress .~o .-~O,~4r~. s~-o~...~/~-, ~ T~Acct. No. '~ C~ssS~ <br />Su~ivision ~d Lot ~ [ Bilk <br />Mobile Home P~ S~ce ~ <br /> <br />S~on Town~p ~nge ~ne Map Wazr Supply: <br /> ~va~Well ( ) S~ng ( ) <br />~ Wi~ ~t ~ Ac~s I~g. Lot ~r ~uMty Well ( ) City ( ) <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> l am the PROPERTY OWNER and own, reside ~n, or will reside in the completed structure and will t~ my own general contractor. I understand that I must ~gi~t~r as a coo~tmcfion <br /> contractor if the structure is sold or offend for sale before or upon completion. If I hire subcontractors, I will hkc only subcontractors registered with the Construction Contractors <br /> If I change my mind and do hire a general ~amWactor who is registend with the Constmctlon Contractors Board, I will immedia~ly notify Marion County of the hang of the contrac~r. <br /> <br /> ( ) I am a CONTRACTOR registered with the Statue of Oregon. <br /> <br /> Business Name Registration No. <br /> <br /> Mailing Address Phone <br /> <br /> ( ) I am an AUTHORIZED REPRESENTATIVE o f the proporty owner or contractor. <br /> Narac <br /> <br /> Mal[thg Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />(1) Permit F~e <br /> <br />(2) 5% Stare Surcharge LOS x Al) <br /> <br />(3) Stnlctarni Phm Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(5) Zoning Sumharge, if applicable (.05% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />/3q. go <br /> <br />I hereby certify that the above information is correct. <br /> <br />(2) Investigation Fee <br /> <br />(3) Reinspoction Fe.~ % $25.00 <br /> <br /> TOTAL <br /> <br />=$ <br /> <br />Permits are non-transferable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. ~o g ~ ~ ~, ~ 7~ 7~' <br />Name of Applicant (Please Prin~,~-~.~4' ~ ~ ,~.._~ ~ <br /> <br />Signatm~ of Applicant: ~ ~/-~--~---..~ Date: 7/~ ~,/9 ? <br /> <br /> <br />