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FOR CITY VALIDATION <br />Received By: __ <br />~onin~ Validation: <br /> <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITy DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone $88.$147 <br /> 24 hr. Iv. spec~ion Line $85-7904 <br /> FAX $88-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />IiFOR CITY USE~ONLY <br /> <br />RESIDENTIAL COMMERCIAL Use of Structure: <br />( )Alteration ( )Other ( )Alteration (~)Sign <br />( )Accessory ( )ChangeofOceupancy ( )Other <br /> <br />:l. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I mn the PROPERTY OWNER and own, reaide in, or will reside in the completed structure and will be my own general conUactor. [ understand that I must register as a construction <br /> <br /> Business Name Registration No. 4~.~ 3 ~ <br /> <br />( ) I am an AUTHORIZED REPRESENTATIVE of the property owne~ or cotsractor. <br /> Name <br /> <br />4. FEE SCHEDULE <br /> <br />(l) Permit Fee <br /> <br />(2) 5% Stat~ Surcharge (.05 x Al) <br /> <br />(3) Structtwal Plan Review 665% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br /> (3) Reinsp~cfion Fee ~ $25.00 <br /> <br />RECEIPT: TOTAL <br /> <br />--$ <br /> <br />1 hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br /> <br />'gZtu~ of Applicant: __ ~~--~ .~ Date: <br /> <br /> <br />