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FOR ~CITY VALIDATION <br />'ReceivedBy: [~_. <br />Zoning Validation: <br />Date: oq _/fit_ ~.~, <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 City Setback Requirements: <br /> Salem, Oregon 97301 1~~ <br /> 8:00am-4:30pm Phone 588-5147 Front: <br /> <br /> 24 HR Inspection Line 588-7904 Left Sid&/ v / ~ Side: <br /> FAX 588-7948 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION ] ~,.~ ~;~J ~j <br /> 1. JOB DESCRIPTION ~-"~=* [~-8 ~5 ~':{ ~"~-~¢',~ <br /> <br /> (~New Placement Garage~Carpo~,) MARION COUNTY <br /> ) Replacement (,>(~A t tac~'EW"~ <br />) AdditionalUnit Add-on ( ) Detached BUILDING IN$?ECTION <br />Dealers.,n~ / /~/ Yearof /~ No. of [Length Width <br />Name:~/~ Manufacturer Sections ~I ~ ~ <br />Type of Siding: Type of R~fing: Square Footage: /~/~. No. of Bedrooms: ~ <br />Wood ~) Comp <br />Metal ( ) Steel Pit Set: Energy: <br />Vinyl ( ) Metal ~ <br /> <br />Job Address: ~jj ~~, Tax Account. #:~A:~t, lpt ~ ~.~ Cross Street. ~,///~,/i. ff~,/~,,~,, ~.~/-. . . <br />Mobile Home Park Name: ~~~~ ~ x ~c~__,~ Space ~: ~ <br />~ope~y Owner~~~/~~ Mailing Address:~~~%~_ ~ Phone No.: ~/~/ <br />Occupant: Mailing Address: Phone No.: <br /> <br />Section: ~ Township: ~ $ Range: ~ ~ Zone: ~ M. Map: <br />Lot Width: ~ ~ Lot Depth: [~,t Acres: Im Lot: ~0 Comer: ~ ~ <br /> <br />Urban Growth Bounda~? ( ) Yes ~ No Water Supply: ( ) Private Well ( ) Co--unity Well ~ity <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 /> 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 property owner or the contractor. <br /> <br />4. FEE SCHEDULE ~ ~/~ ~/ ~/~ff <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.~ = ~- <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 />;~;~ iA;;islc2n~;d(plf~sle8p0ri~t~Y: s~)-t~ ,_~~7-~ .,e PHONE'~2 ~'~Z~"~ <br />MC 15-64 Rev 3/95~t....~~ - <br /> <br /> <br />