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gog C1 Y V ALmA IoN' <br /> .e~¢ived BY: <br /> oning'Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Otegon 97301 <br /> 8:00am-4:3Opm Phone $88.$147 <br /> 24 hr. Inspection Line ~8-7904 <br /> FAX ~88-7948 <br /> <br />COMPLETE ALL SECTIONS, ! THROUGH 4 <br /> <br />' FOR CITY USE ONLY <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL COMMERCIAL,! ~ ~ t' ~"- Use 0f Structure: <br />()Alteration ( )Other ( )AB~I.qIING iNSPECTl{~t~sig. <br />( )Accessory ( ) Change of Occupancy ( )Olher <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am the PROPERTY OWNER and own, rezid~ in, or will ~id¢ in {he comple~cl sWactum ami will be m~' own genoral contractor, I undcmand that !muat o:$htea' Sa a con~tmcfioa <br /> <br />( ~ l'am an AUTHORIZED REPRESENTATIVE of thy property owner or con~ractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See "Valuation $ch~lule' to de2mmin~ valuation based <br /> <br />onsquarefootageofprojeet.) Valuailoa:$ ~0~. ~ <br />(1) P~mit Fee <br />(2} 5% S~ate Sun:harg~ (.05 x Al) /' ~ ~ <br />(3) Structural Plan Review 665% x Al) ,,')., ~, I~,~ <br />(4) Fir~ & Life Safety Plan Review (.40% x Al) <br /> <br />t6)s~,micS.~h~g* = 7/' 25L <br /> <br />TO?AU =s 7/, <br /> <br />I hereby certify that the above information is correct <br />Permits are non-transferable and expi~ if work is not started within 180 days of issuance or if work is s#sl~ndad for !80 days, <br /> <br />Name of ^ppli,ant (Pl--s~ .~~~ C~_ Z~ .on,: <br />SignamveofApplicant: /c.,...,r_...¢~_.. ~,-,-.~ Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />