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FOR CITY VALIDATION I MARION COU~ BUILDING INSPECTION l FOR CITY USE ONLY <br /> ~ ~ /) / f .d I ~I2OMMUNI'J~ DEVELOPMENT CENTER <br />ReceavedBy: {~I"~ o dr- ~'t~6 ][~- ~,mlll~l[285~aurehSt. NE - Room132 /CitySetbackR~qair~m~n~: <br /> ~ . / , · -- -~'~"~V lll~lit~l~I~ / Salem, Oregon 97301 <br />Zomag~Vahdatmn: v'~"'t' I ~~0~_0~m.~_.'30pm Phone S88-5147 ~ <br /> <br />RESIDENTIAL ' COMMERCIAL <br />( ) Addition ( ) Relocation ( ) Addition ( ) New <br />()Alteration ()Other ()Alteration (~gn <br />( )Accessory ( ) Change of Occupancy ( )Other <br /> <br />2. LOCATION OF I~STALLATION ~,~(~,~,L~ <br /> <br /> Mobile Home Pink Sp~ ~ <br /> ~vato Wall ( ) Spring <br /> <br />3. CONTRACTOR INFORMAT/ON -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />() <br /> <br />() <br /> <br />( ) <br /> <br />I am the PROPERTY OWNER and own, reside in, or will r~sld~ in the compleled stmctu~ and will I~ my ow~ general contractor. I tmd~rstand that I must regial~ a~ a cons~racfion <br /> <br />I am a CONTRACTOR r~gister~cl with th~ Stat~ of Oregon. <br /> <br /> Business Nam~ <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the prope~y owner or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br /> Ao VALUATION (Se~ "Valuation Schedule" to d~t~nnthe valuation based <br /> <br />on squar~ foo~ag~ of I~oj~t.) <br />( 1 ) Penvdt F~ <br /> <br />(2) 5% State Surcharg~ (.05 x Al) <br /> <br />(3) Structural Plan R~view (.65% x Al) <br /> <br />(4) Fi~ & Life Saf~y Plan R~view (A0% x Al) <br /> <br />1.93 <br />2.5', 0.~ <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addcedums <br /> (2) lnwsilgafion Fee <br /> (3) R~in~chon Fee @ $25.00 <br /> <br />~c~r: ~/q [ <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-trans ferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />Nameo, Applicant(Pleas, Print): ~t~:~"~ f~)-~'$20 Phone: <br /> <br /> <br />