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FOR C,ITY VALIDATION <br /> <br />Zoning Validation: <br />Date: / ' 3/-c/~'' <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. J DB DESCRIPTION <br /> <br /> I.) New Placement Garage o&arport~) '- <br /> )Replacement (~ Atta~/'""'"~ BUILD/NS <br /> ( ) Additional Unit Add-on C ) Detached MARION COUN~ <br /> <br />Oealers~y~/_ Ye~of No. of I ' <br />Name: --" ~~ Manufacturer /~q~ Sections 3 Length ~ / <br /> <br />(~WoodTff~ of Siding: T[~ Comp°f Roofing: Square Footage:~_.~ ff~d No. of Bedrooms: <br />(t ) Metal { )Steel Pit Set: ./~ Energy: <br />( )Vinyl ( )Metal~ ' <br /> <br />MARION COUNTY BUILDING INSPECTION ] FOR CITY USE ONLY <br />COMMUNITY DEVELOPMENT CENTER .... <br /> 285 Church St, NE - Room 132 ICity Setback Requirements: <br /> Salem, Oregon 97301 ~[Front: Rear: ]~.~ ~ <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 HR Inspection Line 588-7904FAX 588-7948 [Left Side: IRight Side: ....~t <br /> <br /> PERMIT APPLICATION ~ ~~ ~ ~]~ } <br /> -- F£s _ 2 ,'"d <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Address: b~} ~;/~/~ ~ 7"' ITax AcLount: #7 q,_~'-_,~/ I Cross Street: ~// ~d <br />Mobile Home Park Name:~ ~ ~ ~ ~ ~ ~~[~ [ Space~: / <br />Property Owner: ~ Mailing Address: Phone No.: <br />Occupant:~~ ~~ MailingAddress:~q4 ~[~ ~l'~ PhoneNo~/__ ~/5~ <br />Section: ~O Township: ~ Range: ~ ~ Zone: ~ M Map: <br />~tWidth: ~/~ Lot Depth: ~ Acres: Im Lot: ~ Comer: ~.~ <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 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 /> ) I 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 prope~owner or the contractor. <br /> Name: ~ ~ri' " <br /> MailingA~ ~~~ ~"~7 (~ <br />4. FEESCHEDU[E '..~~~X.-, -~, ' ¢76 7/ <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 />· Zoning Surcharge'(if at,pllc~ble) ~ $20.00 <br /> <br /> TOTAL <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 starter[within 180 days of issuance <br />orifworkissuspended for 180days. ~ A l/ . /1~ ~ I <br />NAME OF APPLICANT (pleaseprin,,: C~'~[ ~. ~.~ ~--~ (~"~dE: .--~-- ~'K/-- 3/~/ <br /> : t ~_z-~_~/g_,,r_~ .~.. 7Z/~/~Z/L/ DATE: <br />MC 15-64 Rev 3/95 <br /> <br /> <br />