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IFOR CITY VALIDATION <br /> Recei,~.d By: ' <br />IZ'oningl~/almtion: <br /> Date:' <br /> <br />COMPLETE ALL SECTIONS. 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />~ESIDENTIAL <br /> <br /> ( ) Addition ( ) Relocation <br /> ( ) Alteration ( ) Other <br /> ( ) Accessory <br /> <br />De~cfiptlon of Work <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER I~fl Side: Right Side: <br /> 285 Church St. NE - Room 132 City Setback Requirm~n~: <br /> Salem, O~gon 97301 <br /> 8:00am-4:30pm ?h~i~l~S 147 / <br /> <br /> BUILDING PEI~I]~.~CATI ON <br /> <br /> ( )i 'io ( )New <br /> Changeo mcupancy ( )Omer <br /> <br />2. LO CATION OF INSTALLATION <br /> <br />Job Adda'*.ss ~ I 0 /'~t~*~t -~7"' Tax A~t. No. C~. S~ <br />Mobile Home P~k "' Space ~ ' * '~ '~ ~- ~ <br /> <br />S~gon Town~p Rmge ~ne Map Wagr Supply: <br /> ~va~W~U ( ) S~ ( ) <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SC~DULE <br /> <br /> A. VALUATION (See"Vguafion Schedule"to dateline valuation b~ ~.[ M~cellaneous Fees <br /> <br />on square footage of project.) <br /> <br />(1) Permit Fee <br /> <br />(2) 5% S~atc Surcharge (.05 x Al) <br /> <br />(3) Structural Plan Review (.65% x Al) <br /> <br />(4) Fire & Life Safety Plan Review (.40% x A ]') <br />(5) Zoning Surcharge, if applicable (.05% x A Ih <br />(6) Seismic Surcharge <br /> <br />Valuation: <br /> <br /> (2) Investigation Fee <br /> <br /> (3) Reinspecfion Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed above <br /> <br />RECEIPT: <br /> <br />TOTAL <br /> <br />I hereby certify that the above information is cotxect. <br />Permits ace non- h'ans ~'errable and expire if work is not staried within 1 g0 days of issuance or if work is suspended for 180 days, <br /> <br />Name of Applicant (Please Print): Phone: <br />Signature of Applicant: .Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />