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..IFOR- CITY VALIDATION <br /> IReceived By: __ <br /> IZoning Validation: <br /> [Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <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 /> MANUFACTURED DWELLING <br /> PERMIT APPLICATION <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Front: Rear: <br />Left Side: I Right Side: <br /> <br />( ) New Placement Garage or Carport <br />One) Replacement ( ) Attached <br />( ) Additional Unit Add-on ()~ ) Detached <br />Dealers Year of No. of <br />Name: ~ ~¥1~ ~.J~ Manufacturer <br />Type of Siding: Type of Roofing: Square Footage: <br />(~,) Wood ( ~ Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Mobile Home P~k Name: ~fl~ [ Space~: <br />'Pr°~"yOwner:~n~t$ 4 ~01 ~l~ Mailing Address: ~ ~ ~6 Ph°neN°': ~75- LIl~ <br />Occupant: ~ Mailing Address: ~b Ut ~ O ~ PhoneNo.: __ <br /> <br /> S<tion: 13 Township: 0 ~ Range: 2~ Zone: ~qW Map: <br /> LotWidth: g~t [o~,p~:~3¢ *¢res: ~,0 ~,.~ot: 5~ ~Com~: <br /> <br /> Urban Growth Bounda~? ( ) Yes (~ No Water Supply: (~) Private Well ( ) Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be own general contractor. I understand that I <br /> my <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 /> <br />() <br /> <br />Mailing Address: Phone: JA~ ~ ] 1~ ~ <br /> <br /> ( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. MAR!ON~.~;,,; ;tmm"r~ <br /> L ~ BUILDING INSPECTION <br /> Mailing Address: Phone: <br /> <br />4. FEE SCHEDULE <br /> <br /> A. Manufactured PlacemenffConnections $245.00 = B. Additional Inspection/ <br /> (includes EL, PL, ME connections) (beyond third inspection) <br /> State Surcharge Reinspection Fee $60.00 = <br /> State Fee <br /> Zoning Surcharge (if applicable) <br /> <br />$12.25 = <br />$20.00 = <br />$20.00 = <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 p/~): ~I~hJ/Ok~ h, ]~t~t~ 5~., PHONE: S'75 <br /> <br />SIGNATURE OF APPLICANT: a" ~'~ ~ DATE: [ ~3 <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />