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FOR CITY VALIDATION <br />Received By: ~s ~ ~.~'~ <br />IZoning Validation:. <br />[Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />FOR CITY USE ONLY <br />City Setback Requirements: ~ <br />Lft~*'~!~7~:. ,~ ~-~' RlCtSide: <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 588-51~/-&% ~ f-~ ~---~ r-, <br /> 24 hr. Inspection Line 588-790~ I) } [ ,L~3- / :i <br /> <br /> BUILDING PERMIT APPLI¢~N <br /> <br /> RESIDENTIAL COMMERCIAL guq~lD ~l~e2of Structure: :t M / <br /> ( )Addition ( )Relocation I ( )Addition ~ ~,:g~ / ~~;~.~ <br /> ( ) Alteration ( ) O~er I ( ) Alteration <br /> ( ~o~ [ ( ) Change of Occupancy r <br />Description ofWork &~~M~/~~ ~~~ /~ & ~ ~--~ Is ~is ahistoficflbuil~g? Yes ~ <br />Energy Pa~: No. Stories / ] No. of Employees: Existing - New- ] No. B~ms: <br /> <br />Square Footage -Basement: Main Floor: <br /> <br />2. LOCATION OF IN~ALLATION <br /> <br />Second Floor: <br /> <br />Phone No ~ <br /> <br />Subdivision Lot <br /> <br />Mobile Home Park ~ ~ _ ~ ..... <br /> Range Izone <br />s~o. ~ 1 Tow.,hip tlX I ~ <br />~t Wid~/~0' / ~t ~p~ ~-' I Acres I~g. ~t <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.) <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 Sumharge <br /> <br />Valuation: $ <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />=$ <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 day of issuance or if work is suspended for 180 days. <br /> <br />'g~ PP' : _~~~~ _ Date: _~ --~ <br />MC 15-73 Revl/95.,,,~ <br /> <br /> <br />