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["~ITY VALIDATION] MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY I <br />I ~ ~ , ~ ! COMMUNITY DEVELOPMENT CENTER I I <br />[Receiv~t By: ~ I 285 Church St. NE - Room 132 Ici~, S~ba~k R~qai~a~raa: [ <br />~ ~ -- ~l Salem. Oregon 97301 -- <br />]Zoning?~lidation;-,~,~-~1 ' ~0n~'m-~i3OPmph;ii.$~8-~14~' ~1F~: .-~/ I~' J' ~ I <br />~Ja~g: ~ F~ ~ I ~ I -- I <br /> <br /> No. Bedrooms: <br /> <br />2 LOCA~ OF ~S~LA, TION <br /> <br /> Subdivision ~ t~ ~ · ~ ~ I Lqt [ ~ <br /> <br />3. CON~iOR INF0~I~N: PLEBE I~ICAiEm0'IS DOING THE WO~ <br /> <br />I ~ [ a~ a CO~CTOR ~gis~ Wilh the S~ o f ~g°~. <br /> <br />4. FEE SCHEDULE <br /> <br />AD <br /> <br />B. PERMIT FEES <br /> <br />,2. State Surcharge (~A o f A- I ) <br /> <br />3. P]~ Review Fee (A-2) <br /> <br />Dwelling labels must be obtained at Marion County Building Inspection and must be placed at the Jobsite prior to inspection for plumbing, electrical and <br />mechanical work. Contact Marion County for instructions. <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is smpended for <br />180 days. , , <br />Name of Applicant (Please Print): ~ Phone: ~ "] ~ -- ~ {~'~ <br /> <br />Sigaature of Applicant: l~'~'~h' ) "'-"~':- -~ ~ q _ Date: ~ -- t ~ ~ ~ ~ <br /> <br />MC 15-80 Rev 1/96 <br /> <br /> <br />