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FOR CITY VALIDATION <br /> <br />Zoning Vali~ationf ~///J~c~'~ <br />Date: ~.~ 'o2'r/-G~ , <br /> <br />MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> I <br /> 285 Church St. NE- Room 132 [City Setback Requir~mep~. <br /> Salem, Oregon 97301 IFront: <br /> 8:00am.4:30pm Phone 588-5147 t--~t~a .... <br /> 24 hr. Inspection Line 588-7904 I~l] <br /> BUILDING PERMIT APPLICA~I~" 'A <br /> R 12 1996 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL I COMMERCIAL <br /> <br /> ( )Addition ( )Relocation [ ( )Addition ( )New BU <br /> ( ) Alteration ( ) Other [ (~ Alteration ( ) Sign <br /> ( ) Accessory . , ( ) Change of ?ccup, ancy ( ) Other <br /> <br />Square Footage-Basement~,. I MainFloor: //~t~ Second Hoor: ~ I Garage: .~ <br /> <br />Is this a historical building? Yes - (~ <br /> <br /> No. Bedrooms: <br /> <br />IOther: ~ Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> I Mai'lngAd-ss <br /> <br />Mobile Home Park <br /> <br />Section ~ [ Township <br />Lot Width ~"t9 ~[ Lot Depth <br /> <br />Range <br /> <br />Zone <br /> <br />Irreg. Lot /~0 <br /> <br />Map <br /> <br />Co,~e~ Y~S <br /> <br />Cross Street fy <br /> <br />Block / / <br /> <br />Water Supply: <br />Private Well ( ) Spring ( ) <br />Community Well ( ) City (L.L---'~ <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. B }t~C:~ ~ <br />Business Name Registration No. <br /> <br />Mailipg Addr~ Phone <br />"~ I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Name <br />Mailing Address......__. ---> Phone <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on squarc footage of project.) Valuation: $ <br /> <br /> ( 1 ) Permit Fee <br /> (2) 5% State Surcharge (.05 x Al) = <br /> <br /> (3) Structural Plan Review (.65% x Al) = <br />~ Life Safety plan Revi~ut .Lat/~v"l"A~ ~./,-.L--- = <br /> (5) Zoning Surcharge, if applicable (.05% x Al) = <br /> <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 />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire_if work is ~t started within 180 days of issuance or if work is suspended for 180 days. <br />Name ofApplicant(PleasePrint): ~'/~-----~ ~ ~,~,~d~. ~-/~Phone: <br />Signature of Applicant: Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />