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I~OR CITY VA]eIDATION <br />~e~.~ve3-By: ~ ~ <br />Zoning,Validation: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 255 Church,St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> $:00am-4:30pm Phone 558-$147 <br /> 24 hr. Inspection Line ~88.7904 <br /> FAX 558-794~ <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setheek Requirements: <br /> <br />I~r°nt: ~tg/ R~: ~" / <br />IL~ft Side: ' _~ / mgat side: ..~ / <br /> <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL COMMERCIAL Use of Structure: <br /> ( ) Addition ( ) Relocation ( ) Addition ( ) New ~~ <br /> ( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br /> ('~ Accessory ( ) Change of Occupancy ( ) Other <br />DescfipfionofWork ~_~J ~ Isthisahistofiealbuilding? Yes -~ <br />I No. sto . [ [No. of£mptoyees:Exladng- New- I No. <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile Home P~k ~ Space ~ <br />S~"on ~ ~ Town~p 0 $/ 'Range ~ ~ne ~ M~~ W~rSupply: <br /> ~va~ Well ( ) S~g <br />~w~ [~3 Lo, m~ /qC Acm ~g.~t Com~, <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) i am the PROPEARTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that I must rcglst~' as a conshnwtion <br /> <br /> ( ) <br /> <br />4. FEE SCHEDULE <br /> <br />I mn an AUTHORIZED REPRESENTATIVE of the I~op~r~y owner or contractoL <br /> <br />(2) 5% Stat~ Surcharge (.05 x Al) ~ ~..~.,~ <br /> <br />B. Miscellaneous F~s <br /> <br /> (1) Additiona/Plan Reviews or Addend~ms <br /> (2) Investigation Fee <br /> (3) Reinspecfion Fee @ $25,00 <br /> (4) Other Inspections not lis~d above <br /> <br />RECEIPT: <br /> <br />=$ <br /> <br />I 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 />Name of Applicant (Please Print): . Phone: <br />Signature of Applicant: ~e~.~ //~f Date: <br />MC 15-73 Rev 1/95 ~' <br /> <br /> <br />