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IF. OR CITY VALIDATION <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 hr. Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br /> RESIDENTIAL COMMERCIAL <br /> <br /> ( ) Addition ( ) Relocation ( ) Addition <br /> ( ) Alteration ( ) Other ( ) Alteration <br /> <br /> >q <br />Accessory ( ) Change of Occupancy <br />Description of Work ~J'~[ No. Stodes Y/ '/'""~ ¢ '~- '" No.~of <br />Energy Path: ] Employees: Existing - <br /> <br /> -Basement: Main Floor: { Second Floor: <br />Square <br /> Footage <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br />Use of Structure: <br /> <br />New - <br /> <br />Is this a historical building? Yes <br /> <br /> INo. Bedrooms: <br /> <br />Height: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Address b~" , <br /> <br />Su~vision <br /> <br />Mobile Home P~k <br />S~fion Zff I Towns~p ~ Range ~ <br />~t Wid~ ~~ ~t Dep~ ~ Acres <br /> <br />Lot <br /> <br />Zone ~__dV~Space # X <br /> <br />Cross Street <br /> <br />Block <br /> <br />Water Supply: <br />Private Well ( ) Spring .() <br />Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION m 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 />(g.~"~l am a CONTRACTOR registered with the State of Oregon. <br />Business Name Registration No. <br />! <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br />Mailing Address ~O--~t~t'~:~ Phone <br /> <br />4. FEE SCHEDULE <br /> <br /> A. VALUATION (See "Valuation Schedule" to determine valuation based B. <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 /> ' w ,40% 1)~ <br />(5) Zoning Surcharge, if applicable (.05% x Al) - ' = <br />(6) Seismic Surcharge = <br /> <br />RECEIPT: <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspection Fee @ $25.00 <br /> (4) ~.~;~tions not listed above <br /> <br />TOTAL <br /> <br />=$ <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 (Ple,se Print): ~~-.~ l~ t~/t../ ~ /~')~/.,,~ (-. _~,itJ ) ~f..~ Phone: <br />Signature of Applicant: ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />