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IFOR C, ITY VALIDATION I <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. In~n~i~_ ~ ~,~: ~ ~ ~-'~,"'X <br /> <br /> BUILDING P APPLIC <br /> COMMERCIAL [~GI/qOlIUIX] UUUI'~ I; Use of Structure: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br />( ) Addition ( ) Relocation <br />( ) Alteration ( ) Other <br /> <br /> FOR CItY USE ONLY <br />ICity Setback Requiren~nts: <br />':~°"t: /L,, ~._}o <br /> <br />Is this a historical building? Yes - ~) <br /> <br />~[~Accessory <br /> <br />( ) Addition <br /> <br />( )Alteration <br /> <br />) Sign <br /> <br />( ) Change of Occupancy ( ) Other <br /> <br />Description of Work ~.. ~.- -- .~ ~) / - ~/1~~ <br /> <br />Squ~ F~,ge-B~ement: / [M~,~oo,: ~ [ Seco,d~r: ~ ~~ {Other: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Height: <br /> <br />Pbone~o. '7a,¢- % <br /> <br />Su~ivision ~t <br /> <br />Mo~om~e~k ~ ~~ ~~ ~~~ Soa~ [~ <br />S~fion ~ TownsMp ~ Range <br /> <br />~tWid~ ~V' ~t~p~ /0~ ' Acres /¢]~ ~ ~g. Lot K~~ 7~ <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 />[ 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 />Busin~,N~ Registration No. 4~ <br />Ad.ess .0'7 <br />I am all AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Name <br /> <br />4. FEE SCHEDULE <br /> <br />A. 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 /> <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 @ $25.00 <br /> <br /> (4) Other Inspectioj~s not listed above <br />~E~: P~¢' <br /> <br />=$ <br /> <br />· OXA~ :$ ~¢,g--¢q/ <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 Print): ~ L. %1~.1 .~ Phone: <br /> <br />Signature of Applicant: '~ / ( ~ Date: <br />MC 15-73 Rev 1/95 ~ <br /> <br /> <br />