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~FOR CITY V~IDA'TION,~ <br /> <br />IZonlng Validation: t~' I <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 /> 8:00am-4:30pm Phone 588-5147 / <br /> 24 hr. I ns p e e ti~l]~d~ <br /> Fnxll lSt0 <br /> BUILDING PEm~LIC_ ATION <br /> JUN ? - 993 <br /> <br />FOR crrY USE ONLY <br />L~ft$ide: 0 / Right$ide: /~ / <br /> <br />RESIDENTIAL COMMERCIAL Use of Structure: <br />()Addition ()Relocation () Addmon BUILDING INS~E~,T~N <br />( ) Alteration ~ ( ) Alteration ( ) Sign <br />( )Accessory ( )ChangeofOccupancy (~Other <br /> <br />2. LOCATION OF..~_IHSTt ,LATION --. ,,.-..c~ ,[ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) i am the PROPERTY OWNER and own, reside in, or will reside in the completed s~ucture and will be my own general contractor. I understand that I must mglster as a construction <br /> cona'actor if the structure is sold or offered for sale before or upon completion, ff I him subcontractors, I will hlr~ only subcontractors registorcxl with thc Construction Contractow Board. <br /> If I change my mind and do hire a general conU'actor who is registered with the Construction Con~ractors Board, I will hnmcdiately notify Marion County of the name of the con~ctor. <br /> <br /> ( ) [ am a CONTRACTOR registered with the State of Oregon. <br /> Business Name Registration No. <br /> <br /> Mailing Address Phone <br /> <br />ara an AUTHORIZED REPRESENTATIVE of the property owner or contractor, <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />(]) Pe~t Fee ff~ ~, q3 <br />(3) Stmc~ Plan Review (.65% x Al) ~*~3 <br /> <br />B. Miscellaneous Fees <br /> <br /> ( 1 ) Additional Plan Reviews or Addenduma <br /> <br /> (2) In*csOgafion Fee <br /> <br /> (3) Reinspoction Fee @ $25.00 <br /> <br /> (4} Other Inst~cdons not listed above <br /> <br />TOTAL = $ ~._.~" <br /> <br />I hereby certify that the above information is correct. <br />Permits are non4ransferrable 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 Print): ~, 'g~./ .~"~-__'__'__'__'__'__'__~. t' _ // Phone: <br />Signature of Applicant: ~ .Date: <br />MC 15-73 Rev 1/95 <br /> <br /> <br />