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FOR CITY VALIDATION <br />Received By: ~ .~,~_~,~z~.,/ <br />Izoning Validation: <br />[Date: /o-7-o~ - <br /> <br /> MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY285 ChurchDEVELOPMENTst. NE - Room CENTER132 [lCity Setback Requirements: <br /> Salem, Oregon 97301 [[Front: Rear: /ed ! <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 HR Inspection Line 588-7904 [Left Side: Right Side: <br /> FAX 588-7948 <br /> ! <br /> MANUFACTUREDDWE~~ 'C~3PERMIT ~ ~YE 1~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 APPLICATI-L] ~~ <br /> 1. JOB DESCRIPTION [ !.C 2 0 1~5 ~/...~ ~ <br /> <br />(~) New Placement Garage or Carport <br />Replacement (/.~Attached ~1A R [0 N ~ 0 U N T Y <br />( ) Additional Unit Add-on ()Detached BUILDING IN$?ECTION <br />Dealers ~'~(t.///',~/ Year of [~ No. of [Length I Width~ <br />Name: ~<~ M~ufacturer- Sections 2 ~ 7 <br />Type of Siding: Type of Roofing: Square Footage:ff 7 y No. of Bedrooms: ~ <br />~) Wood ~ Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />b/8 ~.~/~ ~ ~/ Tax Account. #:~.//~j ~?-.~Cross Street: ~,,~/) ~ <br />Job Address: x ~ . <br />Mobile Home Park Name: ~~~ ~~~; Space g: /~ <br />Prope~Owner: ~~~/ ~~ MathngAddress:~ ~[~. ~} Phone No.: ~/~/ <br />Occupant: Mailing Address:~ ~~~ ~ Phone No.: <br /> <br />Section: ~ Township: ~ S Range: /~ Zone: ~ Map: <br /> <br />Urban Growth Bounda~? ( ) Yes ( ~o Water Supply: ( ) Private Well ( ) Co--unity Well <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <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 /> ) am a CONTRACTOR registered with the State of Oregon. <br /> Business Name: Registration No.: <br /> <br /> Mailing Address: Phone: <br /> <br /> ) I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />4. FEE SCHEDULE ~/ff/~ ~ ~aff <br /> <br />Phone: <br /> <br />A. Manufactured Placement/Connections $245.00 = <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 = <br />State Fee $20.00 = <br /> <br /> TOTAL <br /> <br />o'~t~/'~tt'''O B. Additional Inspection/ <br /> (beyond third inspection) <br /> /'~' '°?~" Reinspection Fee <br /> <br />$60.00 = <br /> <br /> 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 AP~~ff~ <br />MC 15-64 Rev 3/95 <br /> <br /> <br />