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IFOR CITY VALIDATION <br />Received By:' ~ <br />Izoning Validation: ~,~ <br />IDate: .~O~,~ ~ <br /> <br />MARION COUNTY BUILDING INSPECTION [ FOR CITY__USE ONLY <br /> 1 <br /> ~City Setback Requirements: <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 HR Inspection Line 588;7904 <br /> FAX 588-7948 <br /> <br />MANUFACTURED DWELLING <br />PERMIT APPLICATION <br /> <br />Left Side' : 't Side' <br /> <br />( ~')'~-ew Placement Garage ~ <br />( )Replacement ( -'~Attached <br />( ) Additional Unit Add-on ( ) Detached BUll.DINS <br />Dealers ~/...A~ ~' Year of No. of Length Width <br />Name: ~../[OsMe~_,..~ Manufacturer ~'p~, Sections 2-- ~/t~ ' 2.7 <br />Type of Siding: Type of Roofing: Square Footage: / ~.~ ~1 No. of Bedrooms: <br />( I,,~ood ( <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~/~) <br /> <br />2. LOCATION OF INSTALLATION , <br /> <br />Mobile Home Park Name: ~/~,~ ~t~ ~~ ~ t~,f Space g: ~ <br />~o~yOwner:~t . ~ I ] .... ~ Mailing Address' ~ ~ ~ ~l ~ I <br /> <br />Occupant: ~~~ Mailing Address: ~ ~ PhoneNo.: ~ &~ <br />Section: ~ Township: ~ Range:~ Zone: ~ Map: <br /> <br />Urban Growth Bounda~? ( ~es ( ) No Water Supply: ( ) Private Well ( ) Community Well (~y <br /> <br />3. CONTRACTOR INFORMATION m 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 ~ame: <br /> <br />Registration No.:~ q~,~ ~} <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Name: ,,--n <br /> <br />Mailing Address: <br /> <br />P~one: 3 tn3 --/7~ ] <br /> <br />Phone: 7~9__ 7.~ ~.~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 <br />(includes EL, PL, ME connections) <br />State Surcharge $I 2.25 <br />State Fee $20.00 <br />Zoning Surcharge (if applicable) <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 />or if work is suspended for 180 days. <br />NAME OF APPLICANT (please pri~-~'~/'~ /~'/~1 ~,~ PHONE: 7b~- 7 ~ ~ <br />SIGNATURE OF APPLICANT: DATE: ~/-/~ ~/~/- <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />