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FOR CITY VALIDATION <br />ReCeived ~l'y: ~ ~ ~-~ <br />Zohing Validation: ~ <br />Date: ?_ ,~2/_ qk <br /> <br /> COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATI <br /> JAN 2 9 N,'~/! ~.~ <br /> <br />1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 ICity Setback Requirements: <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588.5147 [Front: ~_.~/. ]R,e <br /> 24 HR Inspection Line 588-7904 [Left Side: /~~ig~t Side: <br /> MANUFACTURED <br /> <br />( ) Replacement ( ) Attached BIJILDINo.. ~.. COUNDt, <br />( ) Additional Unit Add-on ( ) Detached *nO IlllSP£~Ttr a, <br />Den/ers ~t~.~; Year of t No. of ]Length "a q~Vidth <br />Name: ~//"O/'~'/::~:f Manufacturer ?~:, Sections 2.- qg <br /> I <br />Type of Siding: Type~Roofing: Square Footage: /,~;7 ~ No. of Bedrooms: <br />( 1~9~ood ( ~ Comp <br />( )Metal ( )Steel Pit Set: Energy:/ <br />( )Vinyl ( )M~tal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile. Home Park Name: ~/~~~ ~~,at.~-~ [ Space #: ~ <br />Property Owner: d~/~" -~/t~ ~ Ma~d~'~~ff ~ ~,~ Phone No.: . ~. g~ ~ <br />~cupant: ~~ ~~ Mailing Address: ~ ~ Phone No.: ~ ~.~ <br />Section: 3 'Township: ~X Range: ~ ~ Zone: ~ ~ Map: <br />~t Wide: 7 ~ ~tmp~: / ~ a~re~: ~.[ot: Co~r: ~ <br />Urban Growth Bounds? (~Yes ( ) No Water Supply: ( ) ~vate Well ( ) ~mmunity Well (-~ <br /> <br />3. CONTRACTOR INFORMATION m 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 1 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 />I Business~4~.~Name:L ~,'t,?~] ~ ~-- ' Registration No.: q~p <br />U~i~ g ss.~ <br />135: Phone: <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Mailing Addres~_~ ~ ~ <br /> <br />4. FEE SCHEDULE <br /> <br />Vho.e: 7 6, ~' --7 ? 9X, t <br /> <br />A. Manufactured Placement/Connections $245.00 <br />(includes EL. PL. ME connections) <br />State Sumharge $12.25 <br />State Fee $20.00 <br />Zoning Surcharge (if applicable) <br /> <br />B. 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 />NAMEOFAPPLICANT,pIeaseprin0:.. ,~& ~7: O~t'/~ PHONE: 7/~--,77~t'/~ <br />SIGNATURE OF APPLICANT: ~~'~'..x...~~ DATE: /ff~/'~, <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />