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FOR CITY VALIDATION I <br />Received By: ~-~ <br />IZoning Validatidn: d'~ <br />[Date: ' ~- ,Sl q- q/o. I <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <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 /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />~ ~ alert Sidff: A , '/~cre: - I <br /> <br />1. JOB DESCRIPTION <br /> <br />(~'~ew Placement - Garage or Carport ~t~t~F{IO~ C, OUI~T¥ <br />( ) Replacement ( ~)'~itached BUILDING INSPEC/10~ <br />( ) Additional Unit Add-on ( ) Detached <br />Deflers~*~ ~ Ye~ ofI No. of ] ~ngth [ Width <br />N~e: ~M~ Manufacturer 7~ Sections ~ ~ ~ ~ <br />Type of Siding: Type of Roofing: Squ~eFootage: ~ No. of B~rooms: ~ <br />( ~ood ( ~omp <br />( )Metal ( )Stol Pit Set: Energy:~ <br />( )Vinyl ( )Metal ~0 <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />/ob Address'. ~t..~ ~J'..~l~t y a/~-.~/~Z~.;' ~~ Tax Account. g: I Cross S~t:~/~ ~ <br />Mobile Home P~k Name: ~~~ ~W~~ Space~: ~ <br />~°~"Y Owner: ~~2 ~~ Mailing Address: Phone No-:~ ~/, O 7 ~ ~ <br /> ~t~y~ ~ ~ <br />Occupant: ~ ~ Mailing Address:~e/~ ~ y~, Phone No.: <br /> <br />Section: ~O S Township: ~ ~ R~ge: ~ Zone: ~ Map: <br /> <br />Urban Growth Bounds? ( ) Yes ( ) No Water Supply: ( ) Private Well ( ) Community Well <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 s~ucture 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 /> B~.7.~ame: ~ ' Registration No.: <br /> Mailifie Adah-es s W' <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />Name' · <br /> <br />Mailing A d dre s s :.__.~../~ ~_ <br /> <br />4. FEE SCHEDULE <br /> <br /> A. Manufactured Placement/Connections $245.00 <br /> <br /> (includes EL, PL, ME connections) <br /> State Sumharge $12.25 <br /> State Fee ~. "t-. ,,/,, ~ $20.00 <br />..].~v~"g ~?°b'~rg~ (if appliea$11c-4~""'~ -~'~'_- <br /> <br /> TOTAL <br /> <br /> RECEIPT #: <br /> <br />Phone: ?--Z7 <br /> <br /> B. Additional Inspection/ <br /> (beyond third inspection) <br />~*,~. ~ Reinspection Fee $60.00 = <br /> <br />~'~. 7~' <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. <br />NAME OF APPLICANT (please print,: ~ ~ ~t~V~/~-~I~).~.J-~7/'~ ~'k-~? PHONE: '~t~?--~'7~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />