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IFO. R CITY VALIDATIONI <br />R~c~ix;ed'By: //~ 4 ~1 <br />Izoning Validation: ~'~¢ <br />Ioate: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> ( ) Alteration ( ) Other ( ) Alteration <br /> <br /> ( ) Accessory ( ) Change of Occupancy <br />Description of Work )~2-~t~,.~. ~t~tY t-~ ~9 '/O/ff < <br />Energy Path: / I No. Stories~/o~_~ ] No. of <br /> Employees: <br /> Existing- <br /> Main Floor: .~3 / o~ Second Floor: ~.:~.~ / ~ <br /> <br />Square Footage -Basement: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Ro~-~3g-,:( City Setback Requirements: <br /> Salem Oregon 973~,j <br /> 8:00,m-4:30pm Phone ~ii~/~ <br /> 24 hr. Inspection Line F~Sh79~l" <br /> FAX 588-79~ ~, <br /> BUILD~G PE~IT APPLICATI~, <br /> <br /> COMMBRCIAL [-' ~ ~f~cture: <br /> (~ew <br /> <br /> ( ) Other <br /> <br /> Is ~is a ~stodc~ bu~ng? - <br /> <br />2. LOCATION OF INSTALLATION <br />Property Owner C~[Ii/-/~O ~,4F~.~// L'P~,t~ IMailthgAd~es' ~¢ <br /> <br />Su~vision <br /> <br />Range <br /> <br />Acres <br /> <br />Mobile Home Park <br />Secti°~'-~ (~)/'~ ~,°wnshi, <br />Lot Width ]~0~ ' [ Lot Depth <br /> <br />FOR CITY USE ONLY <br /> <br />Rear: i ~ <br />Right Side: <br /> <br /> Yes <br /> <br /> New - No. Bedrooms: /~_~ <br /> Garage: I~/A [ Other: Height'. <br /> <br /> 3,/.. /f'/ ~r~er, ~re. <br /> <br /> Tax Acct. No. ~~~ Cross S~t <br /> <br /> Bl~k <br /> <br />Space g <br />~ne ~ M Map ~,~_~ Water Supply: <br /> ~vate Well <br />I~g. ~t ~O Comer ~ Co~unity Well <br /> <br />( ) Spring ((t~ <br />( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />(cO`/ 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 />( kY' I am a CONTRACTOR registered with the State of Oregon. <br />Business Name /V/~L~'/]a // &/]-,5//"~¢/b/7 RegistmtionNo. q/~74 <br />MailingAddress.~J~q4 /}¢af'/'~/7 /~tQ'// ~-5E. '7-~/'/Tervb°ne ~/~'-~3 ) 7 I,P- 35¢ 7 <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Name <br />Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on square footage of project.) Valuation: $ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Sumhasge (.05 x Al) <br /> <br />(3) Stmctoral Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br />(6) Seismic Sumharge <br /> <br /> I033., ~ <br />= 51. &5- <br /> <br />= 1~4/. ?s" <br />= <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigation Fee <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br />~CE~: Pb G 3" <br /> <br />=$ <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 />Name of Applicant (Please ~_t ? ~///'/~ ~. /t~¢l~f..~/t~Si~// Phone: <br />Signature of Applicant: ~~. ~// Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />