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FOR CIT~ VALIDATION [ MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLy <br /> . .,,q- 1- ~ z/ [ · ~,ff' COMMUNITY DEVELOPMEbJ~, ~CENTI~ <br /> Received By: ~/..~r .f/~.-~c/r..~ff-~ 255 CborchSt. NE - Ro~]~... Cie/S~tba~R~qaimmaa~a: <br /> ,. · ~'// _] Salem. Omgon97:~J".~'/,~'~/-~. <br /> <br />~ FAX$ L~t$id~: /~ · RightSid~: /~l <br /> BUiLDiNG PERMiT APP~.~ ,ON ~r~/~ ~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 ~a ~/D ~O V/ <br /> <br />1. JOB DESCRIPTION <br /> <br /> 't lt~O~ of SUuetum: <br /> RESIDENTIAL COMMERCIAL ,~ <br /> (~ddition ( )Relocation ( )Addition ( )New ~/~)~72~* <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> ( )Accessory ( )ChangeofOccupancy ( )Other <br />)esefipfionofWork I lsthisahistoficallmilding? y~ . ~ <br />~ergy Path: I No. Stories I No. of Employees: Existing - New * [ No. B ~tmoms: <br />I s o d oo : I I /'' <br /> <br />2. LOCATION OF INSTALLATION //~' <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am an AUTHORIZED REPKE~ENTATIYE of th~ @mp~y ovn~r or mm~'~or. <br /> <br />.3 t,3 -i 7 ~ I <br /> <br />Natfl~ <br /> <br />Mailing Address <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to d=termine valuation <br /> <br />on square footage of project.) <br />(I) Permit Fee <br /> <br />(2) 5% Sta~ Surcharge LOS n Al) <br /> <br />(3) Structural Plan Review (.65~ x Al) <br /> <br />(4) Fire & Life Safety Ptsn P,~view (.40% x A I ) <br /> <br />($) ' ' (~% x At) <br />(6) Seismic Sarchalge ~ "'"~--- <br /> <br />.s 7/. <br /> <br />I hereby certify that the above information is conect. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuanc~ or if work is suspended for 180 days. <br /> <br />Name of Applicant (Please Printk . ~ ~ ~ g~l.~ Phone; <br />Signature of Applicant: ,~l~l~l~~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />