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]F.,OIt,~ CITY VALIDATION I <br /> <br /> Date: ~ t~ ,-'c' '~' <br /> <br />COMPLETE ALL SECTIONS 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 800am-4 30pm Phom~.q~8.-$-147/-- ~ -- ~ V? ~' ~ "~ <br /> 24 <br /> hr. <br /> Inspection <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback R~quimm~nts: <br /> <br />1. JOB DESCRIPTION MARICN ~:. ~ I - <br /> <br /> RESIDENTIAL COMMERCIAL ~ILD~Na <br /> ( ) Addition ( ) Relocation ( ) Addition ~v~ New <br /> ( )^lteralion ( )Other ( )Al.ration ( )Sign <br />  Accessory ( )ChangeofOccupancy ( ) Other <br />DescripfionofWork '~ll~tl 12'~(~-S' ~)[l~. (~'~'~ Is this al~storlcaI building? ¥~- N~ <br />Square Footage -Bas~ment: I Maln bloor: ~) I Second Floor: I Garage: I Other: I Height: ) ~)i <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision Lot Block <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE V/IlO IS DOING THE WORK <br /> <br /> ( ) I am the PROPERTY OWNER and own, resid~ in, or witi reside in the compleuM structure and will be my own genexal contxactor. I understand that I must register as a consum¢fion <br /> contractor ff the stmctur* is sold or offex~d for sale before or upon completion, ff I }dm subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br /> If I change my m~nd and do him a general con~ractor who is registered with the Conslrucfion Con,actors Board. I will immedia~ly notify Marion County of thc name of the contractor. <br /> (~ I am a CONTRACTOR reglztored with thc Stato of Oicgon. <br /> <br />1 mn an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br />~.o~ 36,3-17 t I <br /> <br />4. FEE SCHEDULE <br /> <br /> A. VALUATION (See "V~luation Schexinle" to determine valuation based <br /> <br />B, Miscellaneous Fe~s <br /> (1) Additional Plan Reviews or Addondems <br /> <br /> (2) Investigation Fe~ <br /> <br /> (3) Relnspection F~ @ $25.0~ <br /> <br /> (4) Other Inspections not listed above <br /> qqoq <br /> <br />TOTAL <br /> <br />=$ <br /> <br />MC 15-73 R~v 1/95 <br /> <br />I hereby certify that the above information is con'ect. <br />Permits are non-transferable and expire if work is not started within 180 days of issuance or if work Is suspended for 180 days. <br /> <br /> Phone: 7 -77qq <br /> <br /> <br />