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FOR CITY USE ONLY <br />City Setback Requirements: <br /> <br />FOR CITY VALIDATION [ MARION COUNTY BUILDING INSPECTION <br /> , , .... - -I an COMMUNITY DEVELOPMENT CENTER <br />Received By: (~ ~f~ ~ 285 Church St. NE - Room 132 <br /> <br /> · ~ -- [ t u6~, [ Salem, Oregon97301 <br />Zonmg Vahdation: ___[_* ~____~ [ 8:00am-4:30pm Phone 588-5147 <br />Date' '7 / ,_/n I_ [ 24 HR Inspection Line 588-7904 <br /> MANUFACTURED OWELLIN~ <br /> COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br /> 1. JOB DESCRIPTION <br /> <br /> .~Tin~w Placement Garage o(C~.~a~ BUILU u'~u ..... <br /> ( ) Replacement ~J~Attached <br /> ( ) Additional Unit Add-on ( ) Detached <br /> Dealers ~-'q9 '~/ Year of /qq? So. of__ [ ~¢ <br />: N~e:~~ M~ufacm~r S~tions A ~ <br />I Type df Siding: T~eofR~fiug: Square Footage: ~~ No. of B~ooms: f. <br />(~w~a (~omp <br />( )Met~ ( )Stol Pit Set: Energy. ~ t ~ ~ / <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALL,ATION ~ ~ o~-- ~'~ ° 31 <br /> <br />Job Addres tO,~,.,./~- _ Tax Acc ntl ~: 6'~--~-000 Cross Street: <br />Property Owner: ~ .~.9~,/..~_)~,~,~, Mailing Ad~r;ss.~ ~ ~/~. Phone No.:¢ <br />~cup~t: Mailing Addre~~~ /~ Phone No.: <br /> <br />S~fion: ~O Towns~p: g S Range: ~ ~ ~ne: ~ ~ Map: <br />~t Wide: ~ / ~t ~p~: /& ~ ' Ac~s: lm ~t: Comer: ~ O <br /> <br />UrbanGmw~Boun~7 ( )Yes ( )No Water Supply: ( ) Private Well ( ) Community Well <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />() <br /> <br />I am the 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 /> ~'- ' Add <br /> <br /> ( ) I m an AUtO.ZED ~P~SENTA~VE of ~e pro~ffy owner or ~e contractor. <br /> <br /> Ad. ss: Phone: <br /> <br />4. FEE SC~DULE <br />A. Manufactur~ PlacemenffConn~tions $245.~ = ~ ~ B. Addition~ lns~tio~ <br />(includes EL, PL, ME conn~tions) (~yond third trisection) <br />S~ Su~harge $12,25 = Reinspection Fee $60.00 = <br />Sta~ Fee $20.~ = <br /> <br /> TOTAL <br /> <br />Registration No.: ~ ~~ <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 />NAME OF APPLICANT (please print): <br />SIGNATURE OF APPLICANT: ~ff~~ <br />MC 15-64 Rev 3/95 ~ <br /> <br /> <br />