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FOR CITY ¥ LIDA ON <br />R~ceivcd By: <br /> <br />Zoning Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DI~vELOpMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem. Oregon 97301 <br /> <br /> S:00am.4:30pm Phone $88.$147 <br /> 24 hr. Ingl~-q:fi0n Line S88-7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL COMMERCIAL Use of Structure: <br />( ) Addition ( ) Relocation ( ) Addition ( ) New ~"~ <br />( )AltcratJor~ ( )O~r ( )Alteration ( )Sign <br />( ~ccesso~ ( ) Ch~ge of Occupancy ( ) Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~tWid~l~S' [-0l~pth 9'~') Aem~ I~g,~t ~O Co=r ~O Co~unityWell ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> () <br /> <br /> ) <br /> <br />I am a CONTRA CTOR registered with the State of Oregon. <br /> <br />(~'"" I am an AUTHORIZED REPRESENTATIVE of tlm prOp=r~y owner or ¢onlxacwr, <br /> <br /> I z:_ zz,/ . ..... 6%/ <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />on square~ footage ofprojegt.) Val,~adon; ~ :'?$/,i~. ~ O <br />(1) Permit Fee ,g~/I/. ,~0 <br />(2) 5% State Surcharge (.05 x Al) = ~ ~ :~ <br /> <br />(1) Add{tlonal Plan Reviews or Addendum~ <br />(2) Investigation Fee <br /> <br />=$ <br /> <br />TOTAL <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transt~rrable and expire if work is not star,ed within 180 daya of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Prlnt)j~~. '~ ~: .~ ~ ~ ~ Phone: <br /> <br />Signature of Applicant: ......... /~/{/~--~'~x~~ ~ Date: <br /> <br />MC 15-73 Rev I,n)5 <br /> <br /> <br />