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[ FQI~. CITY VALIDATION <br />R~¢~ived By: ~ <br /> Zoning Validation: '~/~ I <br /> Da : ] <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 $88-7948 <br /> <br />FOR CITY USE ONLY <br /> <br />RightSide: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br /> ( ) Additional Unit Add-on ( · Detached <br />Dealers ~l,~r~ / Year of No. of Leng Width <br /> <br />Ty~ of sadlng: Type of Roofing: Squ~ Eootage~/~a~' No. of Bearooms: ~ <br />(~ Wood ( ~J~Comp <br />(' ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2, LOCATION OF INSTALLATION <br /> <br />Tax Account. <br /> <br />MailhgAd~ess: <br /> <br />Mailing Address: <br /> <br />Phone NO.: <br />Phone No.: <br /> <br /> Urban Orowlh Boundety? ( ) Yes (' ) No Water Supply: ( ) Private Well ( ) Community Well (~City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ( <br /> <br />I am ll~ PROPERTY OWNER and own, reside in, or will reside in the completed smicture and will b¢ my own g~neral contractor. I understand that I <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the prope.~y owner or the conlractor. <br /> <br />Ma~ing Address: <br /> <br />4. FEE SCHEDULE <br /> <br />B, Addillonal Inspection/ <br /> Cocyond third inspection) <br /> Relnspecllon Fee <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance <br />or if work is suspended for 180 days. <br />NAM~ OF APPLICANT (pl~as~ print): "~x v~- e~ Olc ~"I ~,- ~-e~/x.~ S~'~ . PHONE: ~Z CI~ Z 6g~ <br />SIGNATUP, EOFAPPLICANT: ~,:r~t.~nn~'/ ~ ~.,~'~ DATE: ¢--~'*~ <br /> <br />MC 15-64 Rev 3t95 <br /> <br /> <br />