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]FOR CITY VALII~ATION: <br />[Rec~ivecl~By: <br />[Zoning Validation: ~l~ff--=-~ l <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br />( ) Addition ( ) Relocation <br />( ) Alteration ( ) Other <br />(~Accessory <br /> <br />FOR CITY USE ONLY <br />City Selback Requirements: <br /> : t,LC <br /> <br /> COMMUNITY DEVELOPMENT CEN'I-~R <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 24 hr. Inspection Line 588-7904 I ~1~ I ~ ~ <br /> <br />BUILDING PERMIT APPLICATIOI~ ~PR 1 6 1996 <br /> <br /> (~(~ _~c~ q.'~ MARION COUNTY <br />co~c~ 111 ~~: ..... a~/ .... <br />( )Adm~on ( )New ~8~ /~r <br /> <br /> ( )~.~on ()Si~ ~~ <br /> ( )~geof~u~y ( )~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision <br /> <br />Mobile Home Park <br /> <br />Mailing Address <br /> <br />OR' <br /> <br />Tnx Acct. No. <br /> <br />Space # <br /> <br />Phone No. <br /> <br />Block <br /> <br />Water Supply: <br />Privale Well ( ) Spdng ()~' <br />Community Well ~ City <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 lhe completed smacture and will be my own general contractor. I understand that I must mgJstm' as a construction <br /> coma'actor ff lhe structure i~ sold or offea~l for ~qle before or upon completion. If I hire subcontractors, I will hire only subconlractors registered wifl~ th~ ~on Co~rncto~s Board. <br /> If ! change my mind and do hi~ a general contractor who is regisl~'ed with the Construction Conlractor~ Board, I will immediately no~ Marion County of the name of I~e conlractor. <br /> <br /> ( ) I nm a CONTRACTOR ~gistered with the State of O~gon. <br /> <br /> Business Name Registration No. <br /> <br /> blniling Address Phone <br /> <br /> ( ) I am nn AUTHORIZED RE~RF. SENTATIVE of the property owner or contractor. <br /> Name <br /> <br /> Mailing Adch~s Phone <br /> <br />4. FEE SCHEDULE <br />A. B. <br /> <br />VALUATION (See "Vnluafion Schedule" to ~ valuation bzse~, <br /> <br />on square footage of project) Valuation: $ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structmal Plaa Review (.65% x Al) <br /> <br />(4) F~ & Life Safety Plan Review (.40% x Al) <br /> <br />(5) Zoning Surcharge, if npplicable (.05~, x Al) <br /> <br />Miscellaneous Fees <br /> (1) Additional Plan Reviews o~ Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) R '~nsIx~tion Fee O $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-Uansferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Signature of Applicant: ~ ',~. ' '{~ ~ - Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />