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IFOR CITY VALIDATION <br />Received By: ~ <br />Zoning Validation: w <br />Date: d2'r°Z~] <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 /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> ont: ~a~ a~e.~.,j~.) <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 24 <br /> IF~x588.79n41~.~n soection Lie 588-7~.__1_~904/~ ~'~ ~-~ ~'~f ~ ~ <br />MANUFACTUREUI~ ~~ ~ ~ <br /> PERMIT APPL <br /> <br />( f~ew Placement Garage orCarp~ort IVI/AIS, IUIXl bUUIXl I <br />( )Replacement ( )Attached BIJILDING INSPECTION <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers ~,a~t~ff/ Year of Length ] Width~ <br />Name: //'~J',~t" Manufacturer /~,~. No. of <br /> Sections <br />Type <br />Type o~iding: , ~>ofing: Square Footage:/2~ No. of Bedrooms: · <br />( ~fWood ( ,.4-~omp _ <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Address: ~O ~~ ~ Tax Account. ;~.~-;~;' Cross Street: <br />Mobile Home Park Name: ~;5~ .~.~ I Speech: <br />Prope,yOwner:~ _ ~.,./~~ Mailing Address: <br />~cupant: Mailing Address: Phone No.: <br /> <br />Section: ~ Township: ~ Range: ~d Zone: ~ Map: <br /> ~ Lot Depth:~ / Acres: Im Lot: <br />Lot Width: ~ <br /> <br />Urb~ Growth Bounda~? ( ) Yes (~o Water Supply: ( ) Private Well ( ) Community Well <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <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 Name: Registration No.: <br /> <br /> Mailing Address: Phone: <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Name: <br /> <br />] Mailing--Addr? <br /> <br />Phone: <br /> <br />A. Manufactured Placement/Connections <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 = <br />State Fee $20.00 = <br />Zoning Surcharge (if applicable) $20.00 = <br /> <br />$245.00 = ,~O~.~"-, ~t~ B. Additional Inspection/ <br /> (beyond third inspection) <br /> /~/o,~9 ~- Reinspection Fee $60.00 = <br /> <br />TOTAL ~l~t~ &'~g~ <br />RECEIPT #: 9~ 0 <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 priat): ~0 d~'O_J ~ '~ ~ PHONE: t~Z~--Z~~'~ <br /> <br />MC 15-64 Rev 3/95~l~ <br /> <br /> <br />