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MARION COUNTY BUILDING INSPECTION <br />CENTER <br /> 285 Church St. NE - I~ <br /> Salem, Oregon ! <br /> <br /> BUILDING <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRWTION <br /> <br />RESIDENTIAL <br /> <br />~N~ Addition ( ) R~location <br />~teration ( ) Other <br /> <br />( ) Accessory <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requuements: <br /> <br /> -- <br /> <br />COMMF~RCIAL <br />Addition ( ) N <br />Alteration ( ) Sign <br />~upancy ( ) ( <br /> <br />2. LOCATION OF INSTALLATION ~ <br /> <br /> Subdivision -- Block <br /> LotWidtb gt~ LotDeptb ~ll'~ Acres /j IrmgA~ot <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> () <br /> <br /> ¢ <br /> <br />Water Supply: <br />Priva~ Well ( ) Spring <br />~ommunlty Well ( ) City <br /> <br />() <br /> <br />4. FEE SCHEDULE <br /> <br />Ao <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan R¢'Aews or Addendums = $ <br /> (2) Investigation Fee <br /> (3) Reinspecfion Fe~ @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-tcansferrabl~ and expire if work is not started within 180 days of issmmce or if work is suspended for 180 days. <br /> <br />Name of Applicant (Pie Phone <br />S,gnature of Apphcan~ ""~~ .Date <br />MC 15-73 Rev 119:5 <br /> <br /> <br />