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I-I~OR CITYVALI, ONI MARION COUNTY BUILDING INSPECTION ] FOR CITY USE ONLY <br />Received By: ~ ~ COMMUNITY DEVELOPMENT CENTER I -- -- -- <br /> <br />  Salem, (h~gnn 97301 I <br /> Zoning Validation: . [ 285 Church St. NE - Room 132 [City S~tbaek R~quir~n~nt$: <br /> <br /> 8:00am.8:30pm Phone $88-5147 I <br /> Date: ] 24 hr. Inspection ~ $~-7904 [LeA Side: [ Right Side: <br /> FAXS. 7 . --. <br /> <br />COMPLETE ALL SECHONS, ! THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL COMMERCIAL Um of Structure: <br />( ) Addition ( ) Reloeatlon ( ) Addition ( ) New <br />( )~l~eration ()Other ()Alteration ()Sign ~h~p <br />(qeYAccesso~y ( ) Change of Occupancy ( )Other <br /> I Ia this a hiatorical building? Yes - No <br />Description of Work <br /> <br />2. LOCATION OF INSTALLAT10] ~ ,~ .., -- - <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />() <br /> <br />I ara an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> <br />4, FEE SCHEDULE <br /> <br />VALUATION <br /> <br />hereby certify that the above information is correct. <br /> <br />(2) tnv.ttsatlon F~ <br /> <br />(3) Relnspeetion F~ @ $25.00 <br /> <br />permils are non-transferrable and expi~jf~w77t started within 180 days of issuance or if work is suspended for 180 days. <br />Narac of Applicant (Please Print): _ ~ O.j~ ,,~.l Pboue; <br />Signature of Applicant: ~']4'/ ~ Date: <br />MC 15-73 Rev 1/95 ~ <br /> <br /> <br />