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FOR, CITY VALIDATION <br />ReceivfJ By: ~ <br />Zoning Validation: ~ ] <br /> I <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CEN]~ER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am.4:30pm Phone 588.5147 / <br /> z4 hr. I~p~tio. L~Vr~ <br /> FAX <br /> <br /> BUILDING PERMIT API~L"I~ATION <br /> <br /> FOR CITY USE ONLY I <br /> I <br />City Setback Requiromo~: <br /> <br />I.~ftSde: ~/ ~Si~: ~/ <br /> <br />1. JOB DESCRIPTION _~,~.~f~,,~ <br /> <br /> RESIDENTIAL COMMERCIAL <br /> ( ) Addition ( ) Relocation ( ) Addition BtlILBIIIG( <br /> ~ffAlteration ( ) Other ( ) Alteration ( ) Sign ~ ~ t "~ ~'/{2 ~.. /~. <br /> ( ) Accessory ( ) Change of Occupancy ( ) Other <br /> <br />Energy Pa~: I No. S~g~s [No. of ~ployc~: Existing - New - [ No. B~ms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I ara the PROPERTY OWNER and own, reside in, or will reside in the completed stmctur~ and will be my own general contractor. I undersmd that I must register a~ a constmc, fion <br />contractor ff the sm~cture is sold or offered for sale before or upon compleOon, ff I hire subcontractors, I will hire only subeontraetc~ registered with the Construction Corantctors Board, <br />If I change my mind and do hire a general contractor who is registered with the Constmctlon Contractors Board. I will immedbtely notify Marion County of the name of tbe conh-aemr. <br /> <br />I am a CONTRACTOR registered-eagle,'th tbe State of Oregon. <br />Business Name /~ ~'} ~ ~ Regisa'etlon NO. <br />O',q-sE k.~trs;. ~ ,..,,:'r-. ] <br /> <br /> I am an AUTHORIZED REPRESENTATIVE of the geogelxy owner or contmcwr. <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />(4) Plr~ & Lif~ Safety Plan R~vicw (.40% x ^1 <br /> <br />(2) Inveetiietioa F~ <br /> <br />(3) Reinspemion I~e @ $25.~0 <br /> <br />(4) Other Inspections not listed above <br /> <br />TOTAL = $ _~ <br /> <br />I hereby ceaify that the above information is correct, <br />Permits am non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />NameofApplicant(PleasePfint): ff/q-~q._~}.~-~}- fi, F~IiJ~O~ Phone: <br />s,g..o, (Itt f ' ' Da.: <br /> <br />MC 15-73 Rev 1D5 r~/ ~ <br /> <br />, co 3 -74 q- c/3g <br /> <br /> <br />