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FOR CITY VALIDATION <br />Re;eive'd By: ~ <br /> ad,, <br />IZoning Validation: <br /> <br />/Date: /,,~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br />[FO___~R CIT~Y US____E_E ONLY <br />City Setback Requirements: <br /> <br /> Front:t:~,O ~' Rear: ~ ! <br /> Left Side: ~,%-- ~' [Right Side: ~-- ~ <br /> <br /> BUILDING PER¥IT APPLICATION <br /> <br /> RESIDENTIAL ~'~OMMERCIAL ~? Use of Structure: <br /> ( ) Addition ( ) Relocation ( ) Addition ( )New <br /> <br /> ( ) Alteration ( ) Other I ( ) Alteration ( ) Sign <br /> (~ Accessory ~ 0~ ( ) Change of Occupancy ( ) Other <br />Descfipfion of Work ~0.~ 5~ .q6OA'~ [~t[,,9")~,'~ ~/grl,,) '.~/OA ]Isthisahistoficalbuilaing? Yes <br />7 I o. oom : <br />Square Footage -Basement: Main Floor: [ Second Floor: I Garage: I Other.~r.~ <br /> <br />2. LOCATION OF INSTALLATION <br />Mobile Home P~k [ Space <br /> <br />Section <br /> <br />Lot Width 7~' ~%~ <br /> <br />Township ~S ]Range <br />Lot Depth ///..~ 7] Acres <br /> <br />Zone <br /> <br />Irreg. Lot ~'/0 <br /> <br />Map <br /> <br />Comer <br /> <br />Phone No. <br /> <br />Cross <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring <br />Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am thc PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that I must register as a construction <br />contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br />If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br />I am a CONTRACTOR registered with the State of Oregon. <br /> <br />Business Name_ / / Registration No. <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br /> Mailing Address Phone illo. - <br /> <br />4. FEE SCHEDULE <br /> <br />MARION COUNTY <br /> <br />Ao <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) <br />(1) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Structural Plan Review (.65% x Al) = <br /> <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br />(6) Seismic Surcharge = <br /> <br />Valuation: $ <br /> <br />Po, <br />d. 03 <br /> <br />RECEIPT: <br /> <br />Miscellaneous Fees BUILDING INSPE¢]'ION <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspecfion Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> q qq 2.- TOTAL <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 />Name of Applicant (Please Print): ~,~-,, ~ --~'d~ Phone: <br />Signature of Applicant: ~5~57~'~-'~~ Date: <br /> f _..--/ '~v - - - <br />MC 15-7:3 Rev 1/95 <br /> <br /> <br />