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FOR CITY VALIDATION I <br />Received~By: dt.~~ <br />]Zoning Vali. dation: 5'5~/~l' '1 <br />]Date: /,2 -,,Z/a-q.5~ ~ <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 Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 <br /> <br />IFOR CITY USE ONLY <br />City Setback Requirements: <br /> <br /> Front: Rear: /t9 ! <br /> Left Side: Right Side: <br /> <br />1. JOB DESCRIPTION <br /> RESIDENTIAL COMMERCIAL <br /> <br /> A dita n <br /> ( )Addition ( )Relocation ( ) d "o <br /> ( )A. lteration ( )Other ( )Alteration <br /> ( ~)~ccessory [ ( ) Change of Occupancy ( ) Other <br /> <br />Energy Path:,. rNo. Stories / No. of Employees: Existing - New <br />Square Footage -Basement: Main Floor: Second Floor: Garage: <br /> <br />2. LOCATION OF INSTALLATION <br />I PropertyOwner /$~ff~/ ~.~'ff~t,~''' I MailingAddress~ot:'~. ~;~,~,- <br /> <br /> Su~ivision ' ' - ' ~~ ~t <br /> Mo~il~ ~om~ ~k ~ ~ Spac~ ~ /~ <br /> <br /> ~tWid~ ~--~/ ~tDep~ /~ Acres I~g.~t ~ I Comer <br /> <br />Use of Structure: <br /> <br />Is this a historical building? Yes <br /> No. Bedrooms: <br /> <br />Phone No. ,~/f/f/~/ <br />CrossStr~t/~,// ~ ~,L~ <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 the 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 />Business Name Registration No. <br />Mailing Address Phone <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />Ao <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ <br />(1) Permit Fee <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Structural Plan Review (.65% x Al) = <br />.'fa~?L~ & L:t~ ~q~,y ~ian ~evi ~e~(.~.0% :: A!) {~ 7tL~' <br />(5) Zoning Surcharge, if applicable 605% x A 1 ) = <br />(6) Seismic Surcharge = <br /> <br />.be <br /> <br />Bo <br /> <br />RECEIPT: <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other .Inspections not listed above <br /> 97 '/ <br /> <br />=$ <br /> <br />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 /> <br />Name of Applicant (Please Print): .~"~ ~t.~ <br /> <br />Signature of Applicant: <br />MC 15-73 ~ <br /> <br /> <br />