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FOR CITY VALIDATION <br />";cei ed <br />Zoning Validation: ~'~//~// <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br /> 8:00am-4:30pm Phone 588-5147 Front: ~7,~ t' Rear: <br />Date: ~"t,~ "~ ~ ~ HR Ins~tion Line 588-7~n <br /> <br /> MANUFACTU~D DWE~~---- ~ ~ ] <br /> COMPLE~ ALL SECTIONS, 1 THROUGH 4 PE~IT APPLICATI~~ <br /> 1. JOB DESC~ION ~ ~ - ~ ~; ~ ~~ <br /> <br /> ( V'J'~New Placement Garage o~ I¥lfir~lUl~ u~ou~ ~ ~ <br /> <br />( )Replacement (~)AttacheH-- BUILDING INSPECTION <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers ,~DJV,~J/"Z~ Year of t No. of Length ] Width <br />Name: '-~-O s,4tg~ Manufacturer 7~° Sections 2.~ '~/'~I 2 ~ <br />Type of Siding: Type of Roofing: Square Footage: No. of Bedrooms: <br />( ~9~/ood ( ¥9q2omp .. <br />( ) Metal ( ) Steel Pit Set: I Energy: <br />( )Vinyl ( )Metal /~0 -~,/:/, ~, <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile Home Park Name: ~/L~/.~/~ ~/w....7~4_~1- ~k..d'~ ~) i~...{, ]Space#:, 2~ <br />~o~ay Owner: ~ ~~ Mailing Address:/-~ q~ ~ ~qO~ ~ ~Phone <br />~cupant: Mailing Address: Phone No.: <br /> <br />Section: J~ Township: ~S Range: ~ ~ Zone: Z~ Map: <br /> <br />Urb~ Gmw~ Bound? ( ~es ( ) No Water Supply: ( ) P~vate Well ( ) Co~uni~ Well ( ~City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) <br /> <br />I am thc PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that I <br />must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only <br />subcontractors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the <br />Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Na~ae: , Registration No.: <br /> Mailin~t Adth~ss: . ~'/ . ~ <br /> <br />I am ~ AU~ORIZED ~PR~ENTAT~E of ~c pro~Hy owner or the contractor. <br /> <br />Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections <br /> (includes EL, PL, ME connections) <br /> State Surcharge <br /> State Fee <br /> <br />$245.00 = ~"~'- ~ B. Additional Inspection/ <br /> (beyond third inspection) <br />$12.25 = /t~, ~'"' Reinspeetion F~ <br />$20.~ = ~. ~ <br />~ = 3~, 7~ <br /> <br />$60.00 = <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance <br />or if work is suspended for 180 days. <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />