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FOR CITY VALIDATION MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> %,~ -- l COMMUNITY DEVELOPMENT CENTER City $~back Requirementa: <br />Receivett By: ~t. ~4~ /t~-~l~ 285 Church ~. NE -~R~.m 132 <br /> [ ~-} I. J Salem, uregon~/zul <br /> Zoning Validation: [~ I ~. S:00am.4:30pm Phone 588-5147 Front: <br /> <br />m,.. 7 l//el/ / /~'~hr, lnspectionLiae588-7904 I o o <br />I ..... - / -: - -~ / /I~,~/C~t~.. ~ <br /> <br />co~P~ ~LL s~no~s, ~ ~ou~ ~ "q '~ ~ <br /> <br />RESIDENTIAL ff~o~InL o' lO ¥/I/I u~ofst~ct~: <br />,,Addition (,Relocation °~Oi/~ol~0~tO~ ~r.~New ~/ ~ O;~C~ <br />( )Alm~fion ( ) O~er ( ) ~ 77V ( ) Sign <br />( ) A~sso~ ( ) ~ange o~y ( ) O~er <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />$uOdivision Lot Block <br />~cti~m ~.~ Township ~ Range ~,~ Zo~ ~_~ Map ~h WaterSapply: <br /> Private Well ( ) $ pri~ <br />LotWidth ~ · LotDepth ~1~)O't Acres Inzg. Lot ~0 Comer ~.'~(~ CommuuityWall ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SCHEDULE <br /> <br />on square footage of project.) <br /> <br />(l) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Stmcttrcal Plan Review (.65% x Al) <br /> <br />(4) Fire & L~'erSafety_Plan Review (.40% x Al) <br />(s) ' ' "' (.~15% x At) <br />(6) Shismlc Surcharge <br /> <br />B, Miscalla~ous Fees <br /> (1) Additional Plan Reviews or Add~n~ ms <br /> (2) Investigation Fee <br /> <br />TOTAL <br /> <br />=$ <br /> <br />I hereby certify 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 /> <br />Name of Applicant (Please PrinO: ~--~n I~[ <br /> <br /> U/- fL/-- <br />MC 15-'/3 Rev lfg~ <br /> <br /> <br />