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MARION COUNTY BUILDING INSPECTION <br /> <br />IFOR CITY VALIDATION <br />Received By: <br />Zoning Validation: <br /> <br /> Date: =;)/.~2 £,/9 [, . <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> <br /> ( ) Alteration ( ) Other <br /> (.4~ccessory <br /> <br />Energy Path: [ No. Stories /Y / No. of Employees: Existing - <br /> <br /> -Basement: ] Main Floor: ] Second Floor: <br />Square <br /> Footage <br /> <br /> I FOR CITY USE ONLY <br /> COMMUNITY285 ChurChsalem,DEVELOPMENTSt.oregonNE - 97301Ro°m CENTER132 [ City Setback Requirements: <br /> 8:00am-4:30pm Phone 588-5147 IFr°nt: <br /> 24 hr. InspectionFAX 588-7948Line 588-7904 ILeft Side: ~ Right Side: <br /> <br />COMMERCIAL .... ' [ : <br /> <br /> ()Addition I~IARION COU~4~ew <br /> ( )Alteratt~t~JILDIN$ INSP~C~'J~I [ ~'~ '"T /.~/,, .2.5' ' <br /> ( ) Change of Occupancy ( ) Other <br /> <br /> I Is this a historical building? Yes - <br /> New - I No. Bedrooms: <br /> ~R.O' ...~ ~ [Other: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Adar~s ~'PO ~ orae, ..~'". <br /> <br />Subdivision <br /> <br />Mobile Home Park <br /> <br />Lot <br /> <br />Section .~ I Township <br />Lot Width y~} /I Lot Depth <br /> <br />Range <br /> <br />Map <br /> <br />Comer y~..~ <br /> <br />Phone No. ~ ~o ~!l~l~/ ¢ <br />C~oss st~t/t7/4/0 ~o-.tt~t~-l_4~ <br /> <br />Block <br /> <br />Mailing Address <br /> <br />Irreg. Lot ~ <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 him only subeontmctors 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 Adliress <br />- <br />( ) I am an AUTHORIZED REPRESENTATIV~ of the property owner or contractor. <br />Name <br /> <br /> Mailing Addre s ..~ ~ Phone Y 0 ~ - 7 7 ~-~ <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ <br /> <br />(1) Permit Fee 'W'"~" <br />(2) 5% State Surcharge (.05 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 @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />TOTAL <br /> <br />=$ <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 ' 'Et:ix~r_~& 4~'/'~t'/=~' /~j'l~/.~O/- ~,~*~;~.~J Phone: <br /> C.-z :2"'-7/' ' ' <br />Signature of Applicant: ~'~,--- ..~-~/~'- ~'/~ ' ~ ~e..,r L~-)~~ Date: <br /> <br />MC 15-73 Rev 1195 <br /> <br /> <br />