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IFQR CITY.VALIDAT ON <br />II~eceived By: ,.~ (--, <br />IZoning Validati~ <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 /> FOR CITY USE ONLY <br /> <br />Uity Setback Requirements: <br /> <br />Front:~') <br />Side: <br /> <br />Right Side: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br /> 1. JOB DESCRIPTION ~0 d'~ ~_.~ <br /> <br /> ( ) New Placement Garage or Carport <br /> (~) Replacement ( ) Attached MARION COUNTY <br /> ( ) Additional Unit Add-on ( ) Detached BUILDING INSPECTI{ <br /> Dealem L ,.'.s ,., ,' q. Year of No. of [ Length ~ ? [ Width <br />Name: L~.,x._~x,,~ Manufacturer J~ (0 ? SectionsI I r~ ] <br />Type of Siding: Type of Roofing: Square Footage:73,.~ No. of Bedrooms: O~ <br />( )Wood ( )Comp <br />(~,) Metal ( ) Steel Pit Set: Energy: <br />I( ) Vinyl (>e~) Metal <br /> <br />N <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Address: l~l~o FV"e~,~' ~"~ I TaxAcc°unt'#:~O~e~lt'~'~O ICr°ssStreet: <br />Mobile Home P~k Name: Space g: <br />Prope,yOwner: ~. ¢~ ,0.~ ~_~. q~; MailingAddress:~5~X ~*X&O k'~,~ PhoneSo.: <br />Occupant: ~ - -1 - Mailing Address: ~t~ '- ~¢30~ Phone No.: <br /> <br />Section: I [ Township: Ia Range: ~ Zone: ~ Map: ~0 ~ ~ O[ ~ <br />LotWidth: ~ I ~t~pt~S ,~O Acres: ImLot: Comer: <br /> <br />Urban Growth Bounda~? ~ Yes ( ) No Water Supply: ( ) ~vate Well ( ) Co--unity 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 /> <br />Mailine Address: <br /> <br />I am an AUTHORIZED ~PRESENTATIVE of the propeay owner or the contractor. <br /> <br /> Address: <br /> <br />Registration No.: <br /> <br />Phone: <br /> <br />4. FEE SCHEDULE <br />A. Manufactured Placement/Connections $245.00 = ~ t~ ~'1 ~ ~} B. Additional Inspection/ <br />(includes EL, PL, ME connections) (beyond third inspection) <br />State Surcharge Reinspection Fee $60.00 = <br />State Fee <br />Zoning Surcharge (if applicable) <br /> <br />$12.25 <br />$20.00 <br />$2O.00 <br /> <br />RECEIPT #: <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 />NAME OF APPLICANT (please prin~--tt~'~,~~~ ~_ ~~ '~~ PHONE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />