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FOR CITY VALIDATION <br />IReceived BY: ~ <br />[Zoning Vafidation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room <br /> Salem, Oregon 97301 <br /> 8:O{~am-4:30pm Phone 588-2147 <br /> 24 hr. Inspection Line 588.7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL S~ONS, 1 THROUGH 4 <br />I. JOB DESCRIPTION <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />RESIDENTIAL COMMERCIAL Use of S~ructurea. _ <br /> -- ~,'RION COUNTY <br />( )Addition ( )Relocation ( )Addition I. )~'~ t~Ym'P~,id~i~jN.~.4~NSPECTiON <br />( )~[terafion ( )Other ( )Alteration ( )Sign <br />( *9 Accessory ( ) Change of Occupancy ( } Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> () <br /> <br />( ~ [ am an AUTHORIZED REPRESENTATIVE of tlm pmpet~y owner or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (Se~ "Valuation Schedule" to determine valuation based <br />on square footage of project.) Valuation: $ .-~'~/~' ~'~ <br /> <br />(1) Permit Fee <br /> <br />(2) 5% Stat~ Surcharge (.05 x Al) <br /> <br />(3) Stra¢~trul Plan Review (.65% x Al) <br /> <br />(5) ~g Sa~e, ff applicable (.05% <br /> <br />TOTAL <br /> <br />=$ <br /> <br />I hereby certify that the above information is corcect. <br />Permits are non-transferrable and expire ff work is n~ started within 180 days of issuance or if work is suspended for 150 days. <br /> <br />Signature of Applicant: · ,---"x---'x.~*'c_~ ~ ~ Date: <br />MC 15-73 Rev 1]95 <br /> <br />765 <br /> <br /> <br />