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FOR CITY VALIDATION <br />Received By: <br /> <br />Zoning al'dation: 9~ <br />Date: o~ ~':~,/'-~:; <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 City Setback Requirements: <br />Salem, Oregon 97301 <br />8:00am-4:30pm Phone 588-5147 Froot: . /.. <br /> 24 HR Inspection Line 588-790tN r---,. <br /> FAX 588-7948 ].~9)]1~(~'~'~ Left Side?~"~"'*~ ~'~ Right Side:-- <br /> MANUFACTURED DWF~I~ <br /> PERMIT APPLICAT~I <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> ,.JOB...~SCRIPTION qb' ~ Il'lq 2 p -- <br /> <br /> ()Replacement t U UNTy <br />( ) Additional Unit Add-on ( ) Detached o ifilSpF. OTiobi <br />Name: /~,WI ~.¢c Manufacturer / t/',~ Sections <br />Type~93Siding: Type of~ofing: Squ are Footage~,~,/,.~d:9 No. of Bedrooms: <br />('"') Wood ( ,,4'Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Owner:(....~_~'~'~ZT~'~ ~'-~'-J~./~'~.~ Mailing Address: ~J:::J'"' 1~: ~'' ~'~ 'Phone <br /> Pro.ny <br /> No.: <br /> <br />'Section: dO Township: ~ ~ R=ge: ~ ~ Zone: ~'H Map: <br />CotWidth: ~t Cot Depth: /~4t Acres: lm~t:~$ Comer: ~ <br /> <br /> Urbao Growth Bounda~? ( ) Yes ( ) No Water Supply: ( ) Private Well ( ) Community Well <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 /> ( ) [ am a CONTRACTOR registered with the State of Oregon. <br /> Business Name: Registration No.: <br /> <br /> Mailing Address: Phone: <br />(d I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connectlons $245.00 <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 <br />State Fee $20.00 <br />Zoning Surcharge (if applicable) $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 started within 180 days of issuance <br />MC 15-64 Rev3/95J <br /> <br /> <br />