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FOR CITY y~A~I~TION <br />Received By: P $' <br /> <br />Zohing Validation: <br />Date: ]/-- tT--~' <br /> <br />MARION COUNTY BUILDING INSPECTION [FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER [-- -- -- <br /> 285 Church St. NE- Room 132Salem, Oregon 97301 R[C ~ R~quimment~ <br /> 8:00am-4:30pm Phone 588-5147 Rear: <br /> <br /> 24 hr. Inspection Line ~88-7904 <br /> NOV <br /> <br /> BUILDING PERMIT APPLICATION MARION COUNTY <br />COIVlPLETE 3J~L SECHONS, 1 THROUGH 4 BUILDING INSPECTION <br />1. JOB DESCRII~ION <br /> <br /> RESIDENTIAL COMMERCIAL Use of SUacmre: <br /> tion ( ) Other ( ) Alteration ( ) Sign <br /> ( )Accessory ( ) Change of Occupancy ( )Other <br /> <br />Description of Work Is this a historical buildlng? Yes - No <br />Energy Path: [ No. Stories I No. of Bmployee~: Existing- New- [ No. Bddrooms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> I am ~he PROPERTY OWNER and own. r~side in, or will reside in the completed sWactate and will be my own genexal conlr~tor. I understand that I must r~glster as a conslrucfion <br /> <br />4. FEE SCHEDULE <br /> <br />on square footage of project.) Valuallon: $ <br />(6) Seismic S~.harg¢ <br /> <br />I hereby certify that the above information is correct. <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Add~ddums <br /> (2) Inveatigation Fee <br /> (3) Rdnsp~tion Fee ~ $25,00 <br /> (4) Other Ins~ctiolxs not listed above <br /> <br />TOTAL <br /> <br />=$ <br /> <br />Permits are non-txansferrable and expire ff work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />Nmn¢of Applic~t ~lea~ Print): ,~. ,~/~ ~') {'~ ~, ~ Phone: <br />Signature of Applicant: Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />