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IFOR CITY VALIDATION MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> , ~ ,,,,/ /, COMMUNITY DEVELOPMENT C. ENTER <br /> Received By- /r~.,_~, :~ ~ 285 Ch~ch St. NE - R~m ~ ~ 'City Setback Requirement: <br /> ~' - ~ /l~ S~em, Oregon 97301 1~i]~~ ~ <br /> Zoning V~ation: -- ~. 8:00am-4:30pmPhone5~~ ~g~r~t: , ~,~ ~R~ ~ <br /> <br /> BUILDING PERMIT APPLIC~N ~ '~JJ~/ <br />COMPLETE ALL SECTIONS 1 THROUGH n ~. ~/~, 0 1~8 ~ <br />1 JOB DESC~TION r <br /> <br /> ( ) Addition ( ) Rel~ation [ ( ) Addition ( ) New ~ ~~ <br /> ( )~ion ( )O~er [ ( )Alteration ( )Sign /~~/ <br /> ( ~ccesso~ { ( ) Ch~ge of Occupancy ( ) Other <br /> <br />2. LOCATION OF INSTALLATION /,7.-.~-~ XLTt,~'ft.-/--t')-)Pt~c <br /> Property Owner }..~/' I/Al '~"'~-:-~"i~'/' Mailing Address.~.~..~=;-,~./ <br /> ~ .r - .%, ....... .' ',' <br /> <br /> Sulxiivision I Lot <br /> Mobile Home Park ~//.~/~f,.~ ~..---~ ~ ~-7~ 1~7 bd~7,..{ {Space' <br /> <br />Section ,~t9 [ Township g---~ I Range ~.-~ <br />~tWidth ~"~"'""' LotDepth /,9",.~.-/Acres <br /> <br />Irreg. Lot F'I~.~ <br /> <br />Map <br /> <br />Coruer ~0 <br /> <br />Pho.e No. 3 7 P- ? 6,3 ? <br />Cross Street <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 1 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 />(O/~ I am a CONTRACTOR registered with the State of Oregon. <br />Business Narqe Registration No. <br />Phone <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br /> Mailing Address ~ ~ Phone V~' <br /> <br />4. FEE SCHEDULE <br />A. <br /> <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 (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ <br /> <br /> ~e, q3 <br /> <br />B. Miscellaneous Fees <br /> (I) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspe~fions not listed above <br /> <br />=$ <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 />Name of Applicant (Please ~:f _~'"~ ~ Phone: <br />Signature of Applicant: ~'"~-,-'"'~-~/~ ~ ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />