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IFOR C~IT.Y VALIDATION~ <br />Received By: __ <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <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 />IFOR CITY' _USE__ONLY <br />City Setback Requirements: <br /> <br />Front: Rear: <br /> Right <br />IL eft Side: Side: <br /> <br />) New Placement Garage or Carport <br />(~ Replacement ( ) Attached <br />) Additional Unit Add-on ( ) Detached <br />Dealers,,.,~- Year of No. of [ Len~) ]Width <br />Name:~f~'~ ~ Manufacturer Sections <br />' Type of Siding: Type of Roofing: Square Footage: <br />Wood (~) Comp <br /> Metal ( ) Steel Pit Set: Energy: <br /> Vinyl ( ) Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />JobAddress:q~ C~ ~t t,~'~t~. ~'L/'~C~'~ TaxAcc°unt'#/"~/~,'~ Cross Street: .~-,~ <br />Mobile Home Park Name: ~ace #: <br />Pr°pertyOwner:~ ~,~.- /~T~. b~ Mailing Address: ~- Ph°neN°':7~'~q~ <br />Occupant: '~"/~ Mailing Address: ~/~Ot Phone No.: <br /> <br />Section: q Township: ¢ Range: I ~ Zone: Map: <br />Lot Width: Lot Depth: Acres:,~, 3~ In'. Lot: Comer: <br /> <br />Urban Growth Boundary? ( ) Yes ( ) No Water Supply: (~ Private Well ( ) Community Well ( ) City <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 /> ~u~ili~2 SANdad~ffls 5 +~ '4~l'x. ~"~ [~'~ ~1"~ ~'~) [t~ Registrati°n N°': ~ r' ~ ~-,~' 7t:~ 1~ <br /> <br /> I <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />Mailing Address: <br /> <br />Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 = B. Additional Inspection/ <br />(includes EL, PL, ME connections) (beyond third inspection) <br />State Surcharge $12.25 = Reinspection Fee <br />State Fee $20.00 = <br />Zoning Surcharge (if applicable) $20.00 = <br /> <br />TOTAL <br /> <br />$60.00 = <br /> <br />RECEIPT #: <br /> <br />orhiefr~boYrl~srtisufYs;heantdtek;;brOlV8;i~af~sr~, ation~rre,yt. Permits ~n-transferrable and expire if work <br />NAME OF APPLICANT (please print): _~//, I ? ~ ~/~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br />is not started within 180 days of issuance <br /> <br /> PHONE: V(~7~3 <br /> DATE: /~J <br /> 14 195 <br /> <br /> <br />