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IFOR CITY VALIDATION <br />R~eived'By: ~ r <br />Zoning Valid, ation: <br />Date: <br /> <br /> MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 [City Setback Requirements: <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588-5147 Front: Rear: <br /> 24 HR Inspection Line 588-7904 IL~ft Side: I Right Side: <br /> FAX 588-7948 <br /> I <br /> I <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION - <br /> 1. JOB DESCRIPTION <br /> <br />( ) New Placement Garage or Carport <br />~ Replacement ( ) Attached <br />( ) Additional Unit Add-on ( ) Detached <br />Name: ~l~t ~g~, Manufacturer Sections / 70 /' <br />Type of Siding: Type of Roofing: Square Footage: No. of Bedrooms: <br />( ) Wood (~,,~) Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />(~-) Vinyl ( ) Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />M~e Ho~ P~k N~: [ Sp~ ~ <br /> <br />~: Towus~p: ~ge: ~nc: M~: <br /> <br />U~B~? ( )Y~ ( )No Water Supply: ~va~Weli ( )~u~Well ( )Ci~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ( ) I am th~ PROPERTY OWNER and own, reside in, or will reside in the completed structure and will I~ my own general contractor. I understand that I <br /> must register as a construction contractor if thc strocturc is sold or offered for sale before or upon completion. If I hire subcontractors, I :fill hire only <br /> subconlrantors registered with the Coush~uction Con.actors Board. If I change my mind and do hire a general contractor who is registered with th~ <br /> Conslmction Conlractors Boanl, I will immedia~ly notify Marion County of the nam~ of the contractor. <br /> <br /> ( ) I am a CONTRACTOR registered with th~ State of Oregon. <br /> Business Name: l~gistrafion No.: <br /> <br /> Mailing Address: Phone: <br /> <br /> ( ) I am an AUTIiORIZED REPRF~ENTATIVE of the property owner or the contractor. <br /> I Name: <br /> M~iling Addr~s: Phone: <br />4. FEE SCItEDULE <br /> <br />A. Manufactured Placereent/Conncctious $245.00 <br />(includes EL, PI.., ME connections) <br />State 8orcharge $12.25 <br />State Fee $20.00 <br />Zoning Surcharge (if applicable) $20.00 <br /> <br /> TOTAL <br /> <br />B. Additional Inspection/ <br /> (beyond third iuspe~tion) <br /> Reiusi~:lion 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. <br /> <br />SIGNATURE OF APPLICANT: ~'~. ,~' ~ ~'--~ 0"1/I/~./~ DATE: ~/>/ <br /> <br />MC 15-64 Rev 3195 <br /> <br /> <br />