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~OR CITY VALIDATION] MARION COUNTY BUILEF~I~ISPECTION <br /> '~ ,%_ ,- ,~] COMMUNITY DEVELOP~ <br />R~eived By: ~ ~. O~t~'[[~ 2S~ Church St. <br /> /~ it ] Salem, <br /> <br /> B~D~G PE~IT <br /> <br />FOR CITY USE ONLY <br /> <br />I. JOB DESCRIPTION <br /> <br />RESIDENTIAL COMMERCIAL Use of Structure: <br />( )Addition ( )Relocation ( )Addition ( )New r~'~ ~'-~. <br />(~'~'~eration ('~.) Other ( ) Alteration ( ) Sign <br />( )Accessory )~/~r,.~O ~,~ ( )ChangnofOccupancy ( )Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING TIlE WORK <br /> <br /> ( ) I am the PROPERTY OWNER and own, ~slde in, or will reside in the completed structure and will be my own genexal contractor. I understand that I must r~gister as a eonslruetlon <br /> contractor if ~¢ structure is sold or offered for sale before or upon complefon. If I hire subeon~actors. I will hire only subcontractoes ~gistered with h~ Constzuction Contract~ns Board. <br /> <br />4. FEE SCHEDULE <br /> <br />A, VALUATION (See "Valuation Schedule" to d~e valuation based <br /> on square footage of project.) ~: Valuation: $ <br /> <br /> (3) Structural Plan Review (.65% x Al) <br /> <br />TOTAL <br /> <br />=$ <br /> <br />I hereby certify that the above information is correct. <br />Pernfits 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 />Nameofnpplicant(PleasePxint): ~ ~ ~pa'"~(- Phon~: <br />Signature of Applicant: ~ ~X, ~J~ ~X ~ I~ (,.- Date: <br />MC 15-73 R~v 1/95 <br /> <br />7qq- q/tiS <br /> <br /> <br />