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F.0.OR. GITy VALIDATION <br />Received By: <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br /> MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 }City Setback Requirements: <br /> Salem, Oregon 97301 I , <br /> Front: Rear: <br /> 8:00am-a:30pm Phone 588-~['~ ..,. <br /> 24 hr. Inspection Line 588~)~ <br /> FAX 588-7948 [~-~q",.~ <br /> <br /> BUILDING PERMIT A ION <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> <br /> ()Alteration %Ox~X <br /> ( ) Accessory <br /> <br />Description of Work <br /> <br />( ) Addition <br /> <br />( ) Alteration <br /> <br />( ) Change of Occupancy <br /> <br />COMMERCIAL ;:~/.]/[ '/¥17f~i 00, ~q[ Structure: <br /> <br /> ( ) Other x ~ <br /> Is ~is a Msto~c~ building? <br /> <br />Energy Path: [ ~1o. St~ I I No. of Employees: ~isfi~g - New- I So. ~edrooms: <br />Square Footage -Basement: Main Floor:I0~0 ISec°nd ~°°~: I O~a~e: I Ome.: [.eight: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Property Owner L~/~ ]~,~] 33 <br /> <br />Mobile Home Park <br /> <br />Section[ Township ~{~ Range <br /> Wid Lotl,epth It 0 Acres <br /> <br />c173ob <br /> <br />Mailing Address/~ 70f d,/~/ ~,/~,~ ~. 5~r~ <br /> <br />Space # <br /> <br />Zone <br /> <br />Irreg. Lot <br /> <br />Coruer <br /> <br />,bone,,o. <br /> <br />Cross Street <br /> <br />Block q <br /> <br />Water Supply: <br />Private Well ( ) Spring <br />Community Well ( ) City <br /> <br />3. CONTRACTOR/NFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) 1 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 wgister 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 /> <br /> ( ) I am a CONTRACTOR registered with the State of Oregon. <br /> Business Name Registration No. <br /> <br /> Mailing Address Phone <br /> <br /> ( ) 1 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 />on square footage of project.) Valuation: $ ~t~q, <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structural Hah Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(5) Zoning Surcharge, if applicable (.05% x Al) <br /> <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,: ~ "-all )(~3 t~ Phone: <br />Signature of Applicant: ~/./ ~t//~'/~"~ Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />