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FOR C~,TY VALIDATION MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> .~. ~.~ ..4 ! ,,*~_~ COMMUNITYDEVELOPMENT~ <br /> Re~eivedBy: ~.~'~ o~ ~J~ ~1 285 Church St. NE - Room 132 ]~j~ <br /> / ~' ~, [ Salem, O~gon 9730! /_,~]~q~ , <br />{Zoning Validation: ,~r I ,o.. <br /> · t ~ o ~ ~.I~.o. L~ ssa- L~/ s~ .... <br /> / / <br /> <br />COMPLETE ALLSECTIONS. I THROUGH4 ~ *~", <br /> <br /> (~/ff~ddition ( )Relocation ( )Addition ( )New <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> ( )Accessory ( )ChangeofOccupancy ( )Other <br /> <br />Descfip6o~ of Work Is ibis a historical building? yea <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SCHEDULE <br /> <br /> A. VALUATION (Se~ "Valuation ~cbudul¢" to determin~ valuaaon bu~ <br /> <br />(1) Pennlt Fee ..t,.P. ~ <br />(2) 5% State Surcharge (.05 x Al) /' ~'~ <br /> <br />(5,~.~.3 e..,t,o%--. !t-~;!!:_2:. ~,~5% x Al) ~t~ ~ ~ ~' ~ <br /> <br />= 71. ~ <br /> <br /> (3) Relnspecricm Foe ~ $25.00 <br /> <br />· ~a~-,, ~ <br /> <br />IS v <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 er if work is suspended for 180 days. <br /> <br />SignatureofApplicant: / ~a~~.~ .~ Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />