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'~FOR CITY VALIDATION <br />[i~eive. d By: <br /> om~ng Validation: <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 588.5147 <br /> 24 hr. Inspection Line 588.7904 <br /> FAX 588-7948 <br /> <br /> BUILDING PERMIT APPLICATION <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />FOR CITY USE ONLY <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL COMMERCIAL Use ~f S'truc~e: .... <br />()Addition ( ) Relocation ()Addition ()New C~iI~.~ L <br />~ ( ) Other ~ Alteration ( ) Sign <br />( )Accessory ( )ChangeofOccupancy ( )Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Subdivision Lot Block <br />Mobile Home Park Space # <br />Section ~.~ Township ~ Rang, ~/_.~ Zone ~/:;~' Map~.~"~ Wal~rSupply: <br /> Private Well ( ) Spring <br /> () -- <br />LotWidth3,~0~.~'}/ LotDepth J/,~. Acres / Irmg. Lot/ Comer ,~,///,~ CommunityWdl ()City (~)'~'"~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or contractor. <br /> Name <br /> <br /> Mailing Address <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION ($e~ "Valuation Schedule" to d~t~mln~ valuation <br /> <br /> on squa~ footag~ of project.) Valuation: <br /> (1) Permlt F~ <br /> (2) 5% Stat~ Surcharge (.05 x Al) <br /> (3) Structural Plan Review (.65% x Al) <br /> (4) Fife & Life Safety Plan P~vinw (.40% x Al) <br /> <br />Signature of Applicant: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />(1) Additional Plan Reviews or Addendums <br /> <br />(2) Investigation Fee <br /> <br />(3) Reinspection Fe~ ~ $25.00 <br /> <br />,t star~/hin/l ~0 days of issuance or if work is suspended for 180 days. <br /> <br />TOTAL <br /> <br />7 ;q- 20/0 <br />,-/- <br /> <br />=$ <br /> <br /> <br />