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ileOR CITY V~. LIDA.TI/O./~ <br /> eceived By: ~ <br /> °ning Valida%An :_ O~----~ <br /> ate: ~ <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 588.514/ <br /> 24 hr. Inapection Line 58~-7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( ) Accessory <br /> <br />COMMERCIAL <br />( v~Addi6on ( )New <br />( ) Alteration ( ) Sign <br />( )ChangeofOccupancy ( )Other <br /> <br />~ ~ ~_~No. ofEmployees:Existthg-165 New- <br /> <br />Use of Slmcmre: <br /> <br />TNo- Bedroonm: ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Pro~nyowm Shetler & Shetler <br /> <br />Job Address <br /> <br />945 OlneM St. <br />Aumsville OR 97325 <br /> <br />Subdivision ~.~. <br /> <br />IMaillngAddr~ss PO BO2~ 489 <br /> <br />460 IAc~s 10 <br /> <br />Lot Width 9 6 9 Lot Depth <br /> <br />Phone So. 503-749-1900 <br /> <br />Cross st~-t 9 th <br /> <br />Block <br /> <br />Waist Supply: <br />PfivmeWell ( ) Sprin~ ( ) ~ <br />Community Well ( ) C~ty <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) 1 am th~ PROPERTY OWNER and own, reside in, or will reside in the completed st~cture and will be my own genrad contractor. I understand that 1 mast r~gist~r aa a ¢omtmction <br /> conh'actor if thc stmcture is sold or offered for sale before or upon completion. If I hire subcontractors, [ will hire only subcontractors registered with th~ Construction Contractors Board. <br /> <br /> (~ I am a CONTRACTOR registered with thc S~ate of Oregon. 50]~06 <br /> <br /> Blazer Industries, Inc. <br /> Mamn~B~X 489 Aumsville OR 97325-0489 Phone 503-749-1900 <br /> <br />4. FEE SCItEDULE <br /> <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determine valuation based <br /> <br />on ~lUa~ f~otage of project.) Valuation: <br /> <br />( 5 ) Zonthg Surchatge~ if applicable (-~.) ~/~" O~o <br /> <br />(1) Addifiona/Plan Reviews or Add~nduma <br /> <br />(2) Inwstigation F~ <br /> <br />(3) Reinsp~tion Fe~ @ $25.00 <br /> <br />(4) Other bsl~etioas not listed above <br /> <br />=$ <br /> <br />TOTAL <br /> <br />I hereby cetllfy that the above information is correct. <br />P~miin 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 />NameofApplicant(PleasePfint): Marvin R_: Shetle__~r <br /> --v-~ -- _--~----- <br />Signature of Applicant: ~ <br /> <br /> .Phone: <br />__Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />503-749-1900 <br /> <br />01/29/98 <br /> <br /> <br />