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FOR CITY VALIDATION <br />IReceived By: ~ <br />Zoni~ Validation:~. ~ <br /> <br />COMPLETE ALL SECTIONS 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />285 Church St. b <br />Salem <br /> <br /> FAX 5: <br /> <br />BUILDING PERMIT <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirerr~nts: <br /> <br />Front: ~ Rea~: ~ <br />Left Side: ~ Right Sid~2~l-'"~ <br /> <br />RESIDENTIAL COMMERCIAL ' CU~'/( /l/Use of Structure: <br /> ( ) Addition ( ) Relocation ( ) Addition ( ) New 6~ <br /> ( ) Alteration ( ) Other (~ation ( ) Sign <br /> ,^ccesso <br /> <br />Jo~.~ ~/~ ~ ~.~ .o. y~a/o/wa cto~, s~., f ~ <br /> <br />S<tion ~ Township ~ Range ~ Zone ~ ~ Map ~ WamrSupply: <br />~ -~ ~va~ We~ ( ) Spring <br />~tWidlh ~ t LotDepfl~ ~ / Acres l~g.~t Comer ~ ~uMtyWell ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> [ am an AUTIIORIZED REPRESENTA'rlVE of the property owner or contractor <br /> [ Name <br /> Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (See "Valuation Schedule" to determthe ~alaation based <br />on square tbotage of proJeCt ) Valuation: $ ~t~-- <br /> <br />(2) 5% State Surcharge (.05 x Al) <br />(3) S~mctural Plan Review (.65% x Al) ~. <br />(4) Fire&LfeSaeyPanRevew(.40%xA) = <br />(5) Z,>ning S.rch~ge, ff applicableC~5% ~ <br />(6) Seisnfic Surch~ge <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Add~ndum$ = $ <br /> (2) Investigation Fee <br /> (3) Reinspectlon F*e @ $25.00 <br /> <br /> 14) Other Inspections nol listed above <br /> <br /> RECEIPT:. TOTAL = * -~P M '~'~' <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180days of issuance or if work As suspended for 180 days. <br /> <br />Name of Applicant (PI,ase Print): <br /> <br />Signature of Applicant: <br /> / <br />MC 15-73 Rev I:)5 <br /> <br /> <br />