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IOR CITY VALIDATION <br /> eceived By: ~, ~, ~u.,~ <br /> ning Validation: J~' <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> '(, ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other ( ) Alteration <br /> ( ~ccessory ( ) Change of Occupancy <br /> <br />Energy Path: [ No. Stories ~ [ No. of Employees: Existing - <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 City Setback Requirements: <br />Salem, Oregon 97301 <br /> <br /> BUILDING APPLICAT.~ <br /> <br /> COMMERCIAL Iai{Il D~NB ~NSl-' "(J~e of Structure: <br /> ( ) Addition <br /> <br />( ) New <br />( ) Sign <br />( ) Other <br /> <br />FOR CITY USE ONLY <br /> <br />,Left Side: ~t Right Side: <br /> <br />Is this a historical building? Yes - ~(N(N~ <br /> <br />New - ] No. Bedrooms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) I am the PROPERTY OWNER and own, ~side in, or will reside in the compl¢~d sm~cture and will be my own general contractor. I understand that I must regisler es a conslruclion <br />conlractor if lhe sUuctore is sold or offered for sale before or upon completion, ff I hire subcouUactors, I will hire only subcontractors registered with the Coustmctiou Conlractors Board. <br />If I change my mind and do hire a general coutractor who is registered with the Construction Conlractors Board, I will immedialely holily Marion Courtly of the name of the conlractor. <br />(,~ I am a CONTRACTOR reCstered wi~h the $~e of Oregon. <br />Business N~me Registration No. <br />/ <br />( ) I am an AUTHORIZED REPRESI~aqTATIVE of the property owner or contractor. <br />~,~m,,A,:~,,,, ._.? ,¢¢q,,,~,.... ~on~ 7t, 7_Tvyt.~ <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to ~ valuation based <br />on square footage of project) Valuation: $ ~ <br />(1) Permit Nee <br />(2) 5% Sla~e Su~harge (.05 x Al) = ~ <br /> <br />(3) Structural Plan Review (.65% x Al) . = ~ <br /> <br />(5) Zoning Surcharge, ff applicable (.05% x Al) = <br />(6) Seismic Surcharge = <br /> <br />B. Miscellaneous Fees (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Rcinspecfion Fee 0 $25.00 <br /> <br /> (4) Other Inspections not listed ab6ve <br /> <br />TOTAL <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-mmsfen-able 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}; ~A/./ _../,. Phone: <br /> ~...~ . ~/~,' / , - <br /> · . "-.~/~'.,"'_~=': .,29""/~ <br />S~gnamreofApphcant: · ~ - ' ~ g ~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />71~¢- ? ? /dL <br /> <br /> <br />