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Ii.F.O~R CITY VALIDATION <br />eceived By: __ <br />oningValidation: <br />ate: <br /> <br />COMPLETE ALL SECTIONS, I THROUGtl 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 Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED DWELLING <br /> PERMIT APPLICATION <br /> <br />FOR CITY USE ONLY <br /> <br /> ( ) Replacement ( ) Attached <br /> ( ) Additional Unit Add-on ( ) Det~hed ,, <br />l)eal~rs Year of No, of Length Width <br />) Wood ( )Comp <br /> ) Metal ( ) Steel P~t Set: Energy: <br /> )Vlnyl ( ) Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />jPhone No.: <br /> <br /> -- otY <br /> Ma ng Address: <br /> <br /> ~,,o~.. ~ ~ow,,,,,~,. 35, ~=~': /~ '~=: ~ ~"~:. / <br /> <br />3. CONT~CTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING T~ WORK <br /> <br />( ) City <br /> <br /> subcontractors registered with the Construction Conrrar;R~r~ Board. If I change ,ny mind and do hire a gent~at ¢0mra~tor who is eeglst&rad with th~y <br />( ) I am a CONTRACTOR rog!sternal with the Stem of Oregon. <br /> <br />Registration No.: <br /> <br /> () x <br /> <br />4. I*EE SCHEDULE <br /> <br />Manofaeturcd Plat,meat/Connection8 $245,00 <br />(includes EL, PL+ ME redactions) <br />Stl*te Surcharge $12.25 <br />Stat~ F~ $20.00 <br />Zoning Surcharge (if applicable) $20.00 <br /> <br />TOT^L d 7 7, 0~ <br /> <br />$60,00 <br /> <br /> <br />