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Received by.~. c. :: Salem, OR 97301 City Setback <br />[ Z0ning Vali~a~0~' ~/f/~ [ I' 8:~ am4:3~ ~ 588-5147 <br /> <br /> .... <br /> 1, Job D~cfi )fion I, ,' <br /> <br />Residential( ~ New( 1~ Replacemea~t( ) .... Garage or Carport <br /> .... ~, r~nl/M' y( )Attached <br />COmmcrt~ial( ) New( ) Replacement( )[;![,qj~{kJl~ ~,,~q$~ ~ )Detached <br />Serhl~: /~1 Manufacture: q~--[ A~edh~l: ~ I <br /> <br />2. Location oflnslallalion ~gt//,tJ'dO/, ~', &~. ~f~'.i~4''' <br /> <br />Job Addgss .~ff ~S~b*e/~ O/~ . T~ Acct. No. Cross <br />Subdlvi*i~ ...... ,,, ~ I B~k Urban fi'~&th gounda.? <br /> ................. Private Well ( <br /> <br />3, Contractor Information <br />Property Owne~t~A'/ci[g~ ~'~ ~'"'l Mailing Addmaa <br /> <br />IPhoneNo. <br /> <br />own, r~si4e in, of will reside in the Completed structure. <br />understand that I must register as a ¢onstmctien contractor ff the structure i* sold or offel~d for sale before or upon completion. <br />will be my own general contractor <br /> <br />If I cAlange my mind and do hire a general eonhmctor, I will contract with a contractor Who is registered with the Construction Contractors Board, and will <br /> <br />immedhtely n0~y Marion Coumy of the narae of the contractor. ............... /~t~/ ~tLgvlf~a://,e <br />( t,~;'~am a regis~en-n-~ builder OR the authofie~d ~l~Sentafiv¢ of a registered builder. <br /> <br />4. Fee Schedule <br /> <br />A. (I) Manu~actu~edHome <br /> <br /> or Modular Unit Placement/Conneeaon <br /> <br /> ¢) State ~¢e <br /> <br /> (3) Stme Sumha~e <br /> <br />g. (1) Mfg.'d Structure Storage Fee <br /> ~) ~g.'d Structure Smnge Rmewal <br /> <br /> (3) ~ng Surcha~e (15,~ if applicable) <br /> <br />$I82.00-- /ga~.~r~ C. Aaditlonallnspectlcal <br />20.00-- ~. ¢~' or Reinspect/on <br /> 9, I0= ~.tO <br /> ~ = ~ 7. ~0 D. mves~atio~ F~ <br /> <br />f~ $60,00=__ <br /> <br />I hereby ce~ify that the above information N correct and that I have read and understand the Information Notice to ~operty Owner~ about Constructinn Reaponsibilitie~ <br />on the reverse si~ of this foml. <br /> <br /> pp (p 0 prlo ): ~. , ~ ?~./~L ~ Phone' <br /> , '--' 2,.c " ' ' <br /> <br /> <br />