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FOR CITY VALIDATION I <br /> IRe, ceived ~By: d/~. <br />' ]Zoning Validation:/f.~ <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 /> 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 />._etback Require.~ments: <br /> <br /> ( t..'yN-ew Placement Garage or~arpo~ <br /> ( ) Replacement ( ~tac~ <br /> ( ) Additional Unit Add-on ( ) Detached: <br /> Dealers ta~t~LV'"te~Zo~ Year of No. of ~ ~ng~ Wid~ , <br /> N~e: ~t~;~ M~ufactumr l~ Sections ~} ~ ~ ~7 <br /> Type of Siding: Ty~ of Roofing: <br /> (~ Comp Square Footage:/~O ~ No. of B~oms: ~ <br /> <br />[ )-Metal ( ) Steel Pit Set:_,~ Energy: <br />( ) Vinyl ( ) Metal ~ y~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~ ~"'%' /"Ol"~iO~'4~"~Z~:~- } Tax Account. #: } Cross Street: ~l ~ ~~ <br />Job Add.s: ~C ~J~ ~, p~ ~ <br />Mobile Home P~k Name: ~~~ ~~d {SpaceS: ~ <br />Pmpe~y Owner:~ ~ ~~ Mailing Address: Phone No.: ~ ~ , 7~ <br />Occupant: Mailing Address: Phone No.: <br /> <br />on: an e: W Zone: <br />~wi~:~/ [o~p~:~o~ ~re~: ~.~ot: ~ Co~r: & <br />Urban Growth Bounds? ~) 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 />[_. Business Name: t Registration No.: <br />Mg~ng ~tdress: -- .% __ <br /> <br /> te <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />Name: ~ · <br /> <br />Mailing Address: ~ ~ <br /> <br />Phone: <br /> <br />4. FEE SCHEDULE <br /> <br /> A. Manufactured Placement/Connections <br /> (includes EL, PL, ME connections) <br /> State Surcharge $12.25 = <br /> State Fee ~ ~ t $20.00 = <br />_ '?_'7~lng ~l.reharge (if appli~'""tA'~.-8-~0~ = <br /> <br />TOTAL <br /> <br />RECEIPT #: <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.f-~ 0-~/t~ &ttl~r]~./.~.~/ <br />NAME OF APPLICANT (please print,: ,-* ~ a I.~~..~.~.,,,.~.,~ PHONE: <br /> 1 <br />SIGNATURE OF APPLICANT: ~ DATE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />