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' IReceived By: t~ ~'//2ztx,~ [Zoning Validation: ~r~b/ COMPLETE ALL SECTIONS, 1 THROUGH 4 1. JOB DESCRIPTION 8:00am-4:30pm Phone 588-5147 ~'~ 24 HR Inspection Line 588-7904 ] ~J FAX 588-7948 ~~ MANUFACTURED DWEL~ PERMIT APPLICATION FOR CITY USE ONLY City Setback Requirements: ~,~ ..:,, Re~r: id/ ~i~e~ [1 Right Side: MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St. NE - Room 132 Salem, Oregon 97301 1996 ( ~'~w Placement ' - ' - ' G~rag'~ or Carport .... u-,u ii~Ji-'i-i,j i IUI~i ( ) Replacement ( ~ached ( ) Additional Unit Add-on ( ) Detached Dealers ~* / Year of ND. of ] Leng~ [Width Name: /'r//~ Manufacturer /~~ Sections 2 ~ Type ~iding: Type~fing: Square Vootagy~ No. of Bedrooms: y, ( ~ood (~Comp ( ) Metal ( ) Steel Pit Set: Energy: ( ) Vinyl ( )Metal 2. LOCATION OF INSTALLATION $obAddress:~llr9 / '1/ ~ I Tax Account. #: ~ , z~. ~.--'lcrossStreet: ~/_~t~ Mobile Home Pink Name: Z )~ - ~ -- ~ ~Zl~,C I Space g: ~ I ..... - d re s: Z.w ZO% Occupant: ' ' ~ ~ ~ Mailing Address: PhoneNo.: sec"o": ~ *ow~hip: ~ ~n~: ~ Zon*: ~M, ~P: lo, Width: ~ ~pth:/oO' ~: ;~.~o~: (~ Co=~: ~ Urban Grow~ Bounds? ( ) Yes (~No Water Supply: ( ) Private Well ( ) Community Well 3. CONTRACTOR INFORMATION m PLEASE INDICATE WHO IS DOING THE WORK 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 must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractom, I will hire only subcontractors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. I am a CONTRACTOR registered with the State of Oregon. Business Name: Registration No.: Mailing Address: Phone: I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. 4. FEE SCHEDULE ~a/~//~ ~ Phone: A. Manufactured Placement/Connections $245.00 = (includes EL, PL, ME connections) State Surcharge $12.25 = State Fee $20.00 = TOTAL RECEIPT #: $60.00 = hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 NAME OF APPLICANT (please print): X )OA~)~ SIGNATURE OF APPLICANT: MC 15-64 Rev 3/95~ Additional Inspection/ (beyond third inspection) Reinspection Fee PHONE: