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Addition <br /> <br />( ) Alteration <br /> <br />( ) Accessory <br /> <br />[l 6R CITY VALIDATION l MARION COUNTY BUJ~DJ.~C~~~ FOR CITY USE ONLY <br />Igec~i..__a.v_de Bj.v' 10- 285 Church St N~g~ ~v -- -- t'l, I~ I I II~ity Setback R~u~men~'. <br />I' .. .. ~ Salem, ~}e~7~ lllll <br />Ig°mng Xahdatmn: ~ I 8:00am-4:30pm ~1~8-S!47 ~ VIrant: I <br /> . ~ hr. Inspectio~58~ ~ ~ ~' ~ft Side' m t Side' <br />IDate' ~~ I FAX 588-7948 ~ ~ I ' ~ ' <br /> BUILDING PE~IT A~~~I~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 _ B01 lNa 1~SP~Oli0a ~ <br />1. JOB DESC~PTION Q C I / Q <br /> <br /> (,Relocation &&~ ~ <br /> ( ) Addition ( ) New , ~_ <br /> <br /> ( ) Omer ' ' ~ <br /> <br />Description of Work <br />Energy Path: ~ I No. Stories <br />Square Footage -Basement: Main Floor: <br /> <br />( ) Alteration ( ) Sign <br />( ) Change of Occupancy ( ) Other <br /> <br />Is this a historical building? <br /> <br />No. of Employees: Existing - New - No. Bedrooms: <br /> Second Floor: ]Garage: ]Other: [Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> .rty Owner 'iSem'xa <br /> <br />Job Address ~qO [-~ 1~ ~l~--I <br /> <br />Phone No. <br /> <br />Cross Street <br /> <br />Tax Acct. No. <br /> <br />Space <br /> <br />Subdivision Block <br />Mobile Home Park <br /> <br />Map <br /> <br />Comer <br /> <br />Section Township Range Zone <br />Lot Width Lot Depth Acres Irreg. Lot <br /> <br />Water Supply: <br />PfivateWell ( ) 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 contxactor. <br /> <br /> ( ) I am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Name Registration No. <br /> <br /> Mailing Address Phone <br /> <br /> ( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> Name <br /> <br /> Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br />A. <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 />(4) Fire & Life Safety Plan Review (.40% x Al) = <br />(5) Zoning Sumharge, if applicable (.05% x Al) = <br />(6) Seismic Surcharge = <br /> <br />B. Miscellaneous Fees <br /> <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> (4) Other Inspections not listed above <br /> <br />RECEIPT: <br /> <br />=$ <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): <br /> <br />Signature of Applicant: <br /> <br />.Phone <br /> <br />Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />