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~OR CITY V.~. IDATJ~O~N MARION COUNTY BUILDING INSPECTION ] FOR CITY USE ONLY <br />l~ec;ived By: ~-]/~ COMMUi~rY DBVELO?MI~I~rI' CEI~I~ <br /> 285 Chumh St. NE - Room 132 City ~tlmckReqeimn~nts: <br />Izoning Validation: d~ Salem. O~gon97301 Ir~c /~ / [P'~' /O ~' <br /> 24hr. lmpecflon Line $88-7904 [~Si~:/~ / [~S~:~ / <br /> FAX 5~7~ ~ <br /> B~D~G PE~IT APPLICATION ~ <br /> s c o s, 4 <br />1. JOB DESC~PTION G~ >l~ I~ e~ ~ <br /> <br />RESIDENTIAL COMMERCIAL U~e of Stmca~re: z~ <br />( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> <br /> ( )Accesso~ ( ) Ch~geof~cup~cy ( )O~r ~ ~ <br /> <br />2. LO~ATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> Mailing Address Pho~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (Sc~ "Valuation Schedule" to ~ valuation based <br />on squa~ footage of project.) Valuation: $ ~ <br /> <br />(1) Permit Fee .... ~ <br />(2) 5% State Surcharge (.05 x A 1 ) _' ~ <br /> <br />(4) Fire & Life Sa[cry plan Review (,40~ x A I ) <br /> <br />(2) Inveatlgation <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expir~ if work is not stared within 180 days of issuance or if work is susl~dad for 180 days. <br /> <br />=$ <br /> <br />Signature of Apphcant: . Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />