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FOR CITY VA~ <br />Received By: __ <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CEN'I~ER <br /> 285 Church St, NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:3Opm Phone 588-$147 <br /> 24 hr. Inspe~on Line 588.7904 <br /> FAX ~88-7948 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />FOR CITY USE ONLY <br /> <br />BUILDING PERMIT APPLICATION <br /> <br />q <br /> <br />1. JOB DESCRIPTION <br /> <br /> RES .If)~I~'IAL COMMERCIAL Use of smlcture: <br /> <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign ~ <br /> ( )Accessory ( )Change of Occupancy ( )Other <br /> <br />Description of Work Is Ods a historical building? Yes - No <br /> <br />Mobil~ Home Park Space <br /> <br />3. CO/~RACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br />I ~ I am the PROPERTY OWNER and own, ~side in, or witi r~side in the compl~al stmctur~ and will I~ my owtl gcn*ml contractor. I und~md that I must r~gist~r ~ a conmuction <br /> <br />( ) I am an AUTHORIZED REPRESENTATIVE of the prope~y owner or con~xactot. <br /> <br />M~Jling Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br />(1) Permit Fee <br /> <br />(2) 5% Skate Surcharge (.05 x Al) <br /> <br />{3) Sh'uciutal Plan Review (.65% x A 1 ) <br /> <br />(1) Additional Plan Review~ oi' Addcadun~ = $ <br />(2) Investigation Fee <br /> <br /> (5) Zoning Surcharge. if applicable (.05% x Al) <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please pl~t):{ ~ ...,' ~ Phone: <br />Signature of Applicant: ,. '~~~~//] -- Date:~tr,~ ~-- )'~ <br /> <br /> <br />