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FOR CITY VALIDATION <br />]Received By:. L~t~- :~ z~o~ <br />]Zoning Validation: ~'q, ff,~, / <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 HR Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Left idS~e: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br /> 1. JOB DESCRIPTION ~7'~ FEB 2 9 1996 <br /> <br />( b,~w Placement Garage or Carport <br />( ) Replacement (v,') Attached [~/]ARION C0UNT¥ <br />( ) Additional Unit Add-on ( ) Detached BUILDING INSPECTION <br />Dealers ~ OA/IO~t -/..~) Year of No. of Length~..y [Width <br />Name: .~et~el~f Manufacturer ,~ Sections ~ ,/~ <br /> <br />Type of Siding: Type of Roofing: Square Footage: [,Z ~ 0 No. of Bedrooms: ~ <br />( ~Wood ( ~'9"~omp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~)]~} ~t~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Address: ~-~)Yor~ J~'~' Tax Account. #~/~ <br />Mobile Home P~k Name: ~]~~~ ~~O ~ ] SpaceO: ~ <br />Pmpe~ Owner:~~ ~~b~ Mailing Address: Phone No.: ~, ~l ~ <br />Occupant: ~ Mailing Address: ~~ ~ Phone No.: <br /> <br />S<fion: ~ Township: ~ ,~ R~ge: ~a) Zone: ~ Map: <br />~,Width: 7~ ' ~t~p~: /~ 7 ' Acres: Im Lot: / Comer: y~ <br />U~an Growth Bound? (~es ( ) No Water Supply: ( ) ~vate Well ( ) Co--unity Well ( ~ty <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 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 ,sill 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: · <br /> <br /> Mafli_ng Pl, d_d~s.s: _ "' A <br /> <br />Registration No.: <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />NaT'~ & ¢ 0.../,t~ i~~ <br />Mailing Address: X,~j~iA.4 ~.- <br /> <br /> Phone: ._~.._~_ 17/J , <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 = ~"~'~r°~' g-nC2 <br /> (includes EL, PL, ME connections) <br /> State Sumharge $12.25 = ."~,~- '-~'~- <br /> State Fee $20,00 = ~ :"* <br /> Zoning Surcharge (if applicable) $2~:0~= ..,~, ~-~"~ <br /> TOTAL ~'~/d ~ '~' <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 /> <br />MC 15-64 Rev 3195 <br /> <br /> <br />