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MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> <br />IFOR CITY VALIDATION <br />Received By: <br />Zoning Valid. atior/: <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. N.F.,..~ Room 132 <br /> <br /> 8:00am-4:3Opm ~_~-~) ~ ~'~/1'~ ~7~ r -. <br /> 24 HR lnspectioltll4,i~i~-7~tq~,,~ ~ I ~/ <br /> <br /> PE~IT APPLI~~g 1996 <br /> W~RlO~ O00NTy <br /> BUILDIN~ INS <br /> <br />City Setback Requirements: <br /> <br /> ¥ont' 1 <br /> ~ft Side')~°--/~{~t'''.. [ Righ~d;' <br /> <br />( ~qew Placement Garage o~arpo~') .... '-F-'{'iIIO~ <br />( ) Replacement ( ~a~ <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers ~~ ~ Ye~ of / No. of Length Widt <br />Name: ~~ Manufacturer ~ Sections ~ <br />Type of Siding: Type of Roofing: Square Footage: / [ ~ff No. of B~rooms: ~ <br />( ~Wood (~omp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~ ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />J°bAddress:~l~2 w~,~''wwn! ~.t~t ~J- ~l~TaxAccount.~/~ CrossS,eet: <br />Mobile Home P~k Name: ~~ ~ ~~ ~ Space ~: ~ 7 <br />Mail'n 'd' . ~0~ ~ ~, <br />~cupaat: ~~ , g~ aress.~j0~ r~,~7~~ PhoneNo.: <br /> <br />Section: ~ Township: ~' Range:~ Zone: ~ Map: <br />~t Width: ~ Lot Depth: I p~ Acres: lm Lot: ~D Coruer: ~V <br />Urban Growth Bounda~? ( ~s ( ) No Water Supply: ( ) Private Well (.) Co--unity Well (~y <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 /> <br />Business [qame: // '- Registration No.: <br /> <br />I am at] AUTHORI(ED REPRESENTATIVE of the property owner or the contractor. <br /> <br /> Mailing Address: .~~ <br />4. FEE SCHEDULE <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 $20.00 = <br /> ..~n.;.g q,,rc.h~ge (._'f ~_7?!!C~_b!:) -- ~ = <br /> &~ t~ 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 />or if work is suspended for 180 days. _.__... t <br />NAME OF APPLICANT (please ~~ ~ ~ ~ PHONE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />