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FOR CITY VALIDATION I MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> ~ /'- I COMMUNITY DEVELOPMENT CENTER I <br /> Received By: f.~_~o~ ~ ~~ 285 Church St. NE - Room 132 ]City Setback Requirements: <br /> <br /> · .' . . ~' ~t~ [ Salem, Oregon 97301 I <br /> Zoning Validation: S~'/~ ! 8:00am-n:30pm Phone 588-5147 ]Front: IRear: <br />I <br /> k' ~ gg_~gg_~ --~ ~, [ 24 hr Inspection Line 588-7904 ~ [ f i I ',, ' <br /> D re' / -- ~ ~' · I~ t s de: m~ht Side: <br />I a . I FAX 588-7948 ~"~ ~ I I <br /> <br />COMPLETE ALL SECTIONS,, THROUGH 4 /ti; ~ k,~ d ~~ <br />1. JOB DESCRIPTION j~,! <br />miSmENTIAL I COMME~IA-L J. O;aors,l, ct~'~' -.ji/I <br /> <br /> · ~L I~,¥~ , , <br /> ( )A~ration ( )O~er I ( )Alteration ( )Sign &~ ~ [~1~~ ,~~ <br /> <br />:: 02- No <br />Squ~ F~mge -Basement: [ Main Hoot: [ Second H~r: ~;~% ~ I Otber: [Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~o..y Owner <br /> <br />Job Ad.ss ~ <br /> <br />Su~ivision <br /> <br /> .s-z,' <br />IMailing Address ..~-gz-~'~, ~'/~. <br /> Tax Acct. <br /> <br />Lot <br /> <br />Mobile Home Park ~.~:~'"~ ~" ~ <br />s~oou ,~ I T°wns'tiP ~ [ Range ?a.) I Z°ne f~,~ <br />Lot Wid~ ~S i ~t Depm / D 0 I Acres I~g. Lot fi0 <br /> <br />Space# /2-~ <br /> <br />Map <br /> <br />Comer <br /> <br />Phone No. 7~f - Z t~'""' <br />Cross Street/f~/C~ ~, <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 contxactur who is registered with the Construction Cona'acturs 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 /> <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> Name/2___~,' c~.._.~,e~.=~ ~ ~)/~t~' ~--"~ <br /> <br />4. FEE SCHEDULE <br /> <br /> A. VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) <br /> <br />( 1 ) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br />(6) Seismic Surcharge <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br /> RECEIPT: ~9 ~ <br /> <br />=$ <br /> <br />TOTAL =$ g("f~. ~ <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 Pfi~ ~ ~ ~ Phone: <br /> <br />Signature of Applicant: ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />