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FOR CITY VALIDATION MARION COUNTY BUILD~G INSPECTION [ FOR CITY USE ONLY ] <br />IReeeivedBy5 C~'h/,d- ~'~r,~,l~e.. 285 Church SL NE :-j~611~ I~ · <br /> <br /> ' -- Salem, Oregon <br /> <br />Ir,~t~· ~I~-, lq~ / ~ ~. ~.o. L~.i.~ <br /> · , . FAX $g8-7945 JU4~ ~ Si~C. ~Rl~llt Side: ~O.~.~j <br /> BUlU i GPE ,T.? csl %///1 <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 ~O[~7~;O]/~s{ ~/S6~ ~ <br />,.jo sc oN /,v,s 'O- <br /> <br /> RESIDENTIAL COMMERCIAL ' ~ of Struc0.1re: r .,r ~ ~ <br /> ( ) Addition ( ) Pa~locafion ( ) Addition ( ) New ~ O ~ <br /> ( )Alteration ( )Other ( )Alteration ( )Sign /a~ta,,9~'t <br /> ( rg'~ccessory ( ) Chang~ of Occupancy ( ) Other <br /> <br />~y P~: INo. S~o~ i ] ~o. ~ ~,oy~: u~a,~- ~w- ] No. ~oom,: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> () <br /> <br />MgillngAddl~ss ~ ~:~ no~ 7~'7' Z7~/-5~ <br /> <br />4. FEE SCHEDULE <br />A. I B. Miscellaneous Fees <br /> <br />(1) Additional Pla~ Reviews or Addendums <br /> <br />(2) Investigation Fee <br /> <br />(3) R¢inspection Fe~ @ $25.00 <br /> <br />=$ <br /> <br />TOTAL =$ ~'~' ~ <br /> <br />I hereby certify that the above information is con'ect, <br />Permits are non-transferrable and expire if work is not stared within 180 days of issuance or if work is suspended for 180 days. <br /> <br />NameofApplicant (PI~~~. __Phone:./l'~:~'' ~7~ <br />Signature of Applicant: ! .Date: ~ ~ <br />MC 15-73 Rev 1~5 <br /> <br /> <br />