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FOR CITY VALIDATION <br />Received By: ~ <br />Zoning Validation: ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 24 hr. Inspection Line $8~.7~.~ FAX $88-7948 <br /> <br /> BUILDING PERMIT APPIxI.~.A~ION <br /> <br /> FOR CITY USE ONLY <br /> <br />2ity Setback Requflem~ats: <br /> <br />( )~i~n ( )Relocation ( )Addition ( )New <br />(t"9~Alteration ( ) Other ( ) Alteration ( ) Sign <br /> <br />( ) Accessory ( ) Change of Occupancy ( ) Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> ~va~ Well ( ) S~ng <br />~tWida~]g ~t~pa ~g~ Acres /' l~g.~t / Comer / Co~ai~Well () City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SCHEDULE <br /> <br />(1) Permit Fee <br />(2) 5% State Surcharge 605 x Al) <br />(3) Structural Plan Re'flew (.65% x Al) <br />(4) Fire & Life Safety Plan Review 640% x A 1) / = <br /> <br />(6) Seismic Surcharge <br /> <br /> Miscellaneous Fees an Re~/de~Ad <br /> (I) Additional H enduros <br /> (2) Investigafion~,q~ <br /> (3) Reinspe~ffn Fee ~ $25~0 <br /> (4) O~ Inspections not listed above <br />RECEfPT: ' ~'7. ?~ O TOTAL <br /> <br />=$ <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 Prtht ): ~'--4 U'~'~--~-" ~ ~'~'~[~'~'-ff'/~-~ ~,-~ Phone: <br />SignatureofApplicant:-ff~-~'d ] er k,/ //¢4.~t r"~L'~, ,e )__ Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />