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FOR CI. TY VALm TION MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br /> · - ,.4~ / t ~ COMMUNITY DEVELOPMENT CENTER -- -- <br />IReueived By: t L.~ O--O,b~ [ 285 Church St. NE - Room 132 [Ciry ~c_k Requirements:.~-~ <br /> - /~ Sal 9 01 ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 UA~ION <br />1. JOB DESCRIPTION {:}llll nlm,r, , ........ --- .llll~ ,.. <br /> RESIDENTIAL COMMERCIAL .... "'lvorrbl{ INUseofStmctur~:"" <br /> ()Addition ( )Relocation ()Addition ()New <br /> ()Alteration ( )Other ( )Alteradon ()Sign ~JrlJl'~zlJV6 INSPEOTIO~ <br /> ( Accessory ( ) Cha~ge of Occupancy ( ) Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Marlin Address. ~ ~' j~ DX $1.. · ~' <br /> <br />~ ~n~ ~ ~ Map W~, Supply: <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am tho PROPERTY OWNER aad own. reaide in, or will reside th the completed sUuctum and will be my own general contractor. I understand that I must register as a consUu~on <br /> con,actor if thc s~ruetum is sold or offered for sale before or upon ¢omplalion. If I hire subconU'actors, I will him only subcontractors registered with the Construction Contractors Board. <br /> ff I chang~ my mdnd and do him a general conlmactor who is registered with the Construction Con,actors Boatd, I will immediately notify Marion County of ~c name of the contractor. <br /> <br /> (,~ I am a CONTRACTOR registered wlth the S~ate of Oregon. <br /> <br /> Busi~ss Nmu~ , Registration No. <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the properly ovnu~ or ¢on~ractor. <br /> <br />4. FEE SCH'.~J~ULE <br /> <br />on squag footage of project.) Valuafica: $ ~ I~- ~ <br /> <br />(1) Additional Plan R~viw~'s or Addendums <br /> <br />(2) Investigation Fee <br /> <br />(3) Ralnspeefion Fee @ $25.00 <br /> <br />=$ <br /> <br />TOTAL = $ <br /> <br />1 hereby certify that the above information is eon'eot. <br />Permits are non-h'ansferrable and expire if work is not stazmed within 180 days of issuance or if work is suspended for 180 days. <br />Name of Applicant (Please ~'intk ~ ~ 4 ~} ~ ~ Phone: <br />Signature of Applicant: ~ Date: <br /> <br />MC 15-73 P~v 1/95 <br /> <br /> <br />