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FOR CITY VALIDATJON Received By: ~ 1~ ~ IZoning Validation: ~5~'.~ · IOate: MARIONcCo2yuNm~T~BvU~IoLpD~N~GcJNNT~S?ECTION [ FOR CITY USE ONLY 285 Church St. NE - Room 132 ]City Setback Requirements: Salem, Oregon 97301 ]Front: Rear: 8:00am-4:30pm Phone 588-5~ 24 HR Inspection Line 588-7~i FAX 588-7948 lg( ~ ~ ~ ~ ?~{~id RightSide: MANUFACTURED DWI~NG COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION 1. JOB DESCRIPTION q[:?'(.~D 0 ~ I.O ~<~;New Placement Garage or Carport BUILDING INSPECTION ( ) Replacement ( t~Attached ( ) Additional Unit Add-on ( ) Detached Dealers d~?e'L~0~/ Year of / ~g ~.~ ND. of [Length I Width Name: g/~ ~t~fi- Manufacturer Sections 2 ~' ~ Type of Siding: Type of Roofing: Square F°°tage:/O~'"'O~'~ N°' °f Bedr°°ms: ( )'9 Wood ( r~-Comp ( ) Metal ( ) Steel Pit Set: Energy: ( )Vinyl ( )Metal 2. LOCATION OF INSTALLATION ~ib~ 1 2 L/N a~m e ~~,~_t~'/""~LO' fi'/ Tax Acc°unt' ~:~~/~ce[~r°ss Stm~,// ~f ~ ~, ' ~e~.o~: ~ I~°wn~: ~S ~a~e: / ~ z°~:~M ~p: [o, Wia,~: ~--~ ' ~t ~: /~' ~cre~: I~. ~o~: ~0 Co=r: ~0 Urban Growth Bounda~? ( ) Yes (~o Water Supply: ( ) Private Well ( ) Community Well (~ 3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK ) 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 must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If 1 hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. ) I am a CONTRACTOR registered with the State of Oregon. Business Name: Registration No.: Mailing Address: Phone: ) 1 am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. 4. FEE SCHEDULE Phone: A. Manufactured Placement/Connections $245.00 (includes EL, PL, ME connections) State Surcharge $12.25 State Fee $20.~ TOTAL RECEIPT #: q d' £ / B. Additional Inspection/ (beyond third inspection) Reinspection Fee $6O.00 = 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 or if work is suspended for 180 days.~ NAME OF APPLICANT (please print):, ~ _~_X,~_ MC 15-64 Rev 3/95 PHONE: