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IFOR CITY VALIDATION <br />Received By: &.,, //~ <br /> Zoning Validation:I U~, , <br /> 24 HR Inspection Line 588-7~4 ]Left Side' <br /> MANUFACTURED D~~O~ ~ <br /> <br />MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br /> COMMUNITY285 ChurchDEVELOPMENTst. NE - Room CENTER132 I[City Setback Requirements: ~ <br /> Salem, Oregon 97301 [Front: ~//~Rea~' ~/~ . <br /> 8:00am-4:30pm Phone 588-5147 <br /> <br />~'~ New Placement T .~ Garage o~m~r~//,n~ <br />( ) Replacement ( ~ Attache~//~, <br />( ) Additional Unit Add-on ( ) Detached <br /> <br />Nme: . Manufacturer Sections <br />Type of Siding: Type of Roofing: Square Footage://~/~- No. of Bedrooms: <br />(~ood (~omp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCAT, ~}F INSTALLATION <br /> <br />Mobile Home Park N~e: ~~~ ~, ~ ~~~ I Szaceg: _~ <br />Prope~y Owner~ ~~/~.~ M:iling Address: ~ ~. (~¢T Phone No,: ~/__~/¢/ <br />Occupant: Mailing Address: Phone No,: <br /> <br />Section: J~ Township: ~5 Range: ~ ~ne: ~ Map: <br />Lot Wide: ~ / Lot Depth: /~ t Acres: I~. ~t: ~0 Comer: ~ <br /> <br />Urban Growth Bounda~? ( ) Yes ( ) No Water Supply: ( ) Private Well ( ) Community 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 /> I Business Name: Registration No.: <br /> Mailing Address: Phone: <br /> / <br />(d I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />A. Manufactured PlacemenffConnections $24S.00 <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 <br />State Fee $20.00 <br /> <br /> TOTAL <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Reinspection Fee <br /> <br />$60.00 = <br /> <br /> 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 /> <br />SIGNATURE OF APPLICANT: ~ ~~~ DATE:_~-'"'~/'~ ~'/~' . <br />MC 15-64 Rev 3/~ <br /> <br /> <br />