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FOR CITY V~LIDATION <br />Received By: <br />]Zoning Validation: <br />IDate: /-,~ .3 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 HR Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> FOR CITY USE ONLY I <br /> I <br />City Setback Rexluirements: <br /> <br />Front: Rear: /0 l <br />Left Side: Right Side: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br /> <br /> New Placement ..... Garage o~'~arpo~.~ <br /> (~) Replacement (~ Attac~ ~lO~ <br /> ( ) Additional Unit Add-on ( ) De~ched ~11 <br />De,em ~~ Ye~of ~ No. of [~ng~ ..... <br />N~e: ~ Manufacturer ~ Sections <br />Ty~ of Siding: Type of Roofing: <br />~ Wood ~ Comp Square Footage: <br /> <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~ <br /> <br />2. LOCATION OF INSTALLATION q'.5'- 3 ! <br /> <br /> ~ ~ ~ V/,~t ~. Tax Account. <br />Mobile Home P~k N~e: ~/~ ~ ~ ~ ] Space g: <br />~o~y Owner: ~ Mailing Address: <br />mcupant: ~ ~ ~ Mailing Address: <br /> <br />S=tion: ~ Township: ~ S Range: [ W Zone: /M Map: <br />~t Widm: ~ Lot Depm:/ 0 0 Acres: Im Lot: <br /> <br />Urban Growth Bounda~? (~ Yes ( ) No Water Supply: ( ) P~vate Well ( ) Community Well ~City <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 stmctum 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 ,.viii hire only <br />subcontractors registered with the Construction Contractors Board. If l 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 />Business ~Name: .// · Registration No.: <br /> <br />M~ajli~g 4114ress: __ __ ~ <br /> <br /> / <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />Na~ ¢ <br />Mailing Address: <br /> <br />4. FEE SCHEDULE <br /> <br />g. Manufactured Placement/Connections $245.00 = O~4~e,~, <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 <br />State Fee $20.00 <br />Zoning Surcharge (if applicable) <br /> <br /> TOTAL <br /> <br />Phone: <br /> <br />Additional Inspection/ <br />(beyond third inspection) <br />Reinspection Fee <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 />NAME OF APPLICANT (please~ ~, ~ PHONE: ,, ,-,,fl'~ <br />SIGNATURE OF APPLICANT: *r t....'~-.~ -- -,__., , ~{_~j~,,~ DATE: /--Z--~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />