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IFOR CITY VALIDATION [ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIIrfION <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 58~/~ ~ C~ c.~ ~ <br /> 24 HR Inspection Line $8~[~i.~ [ [ ~ I ~- ] ~"~1 <br /> <br /> MANU ACTUREO OV 'r; G <br /> PERMIT APPLICA'T/ONAp]~ ~'3 1996 <br /> <br /> (~C~New Placement '- c.,-~eorc~UILDING INSPECTION <br /> ( ) Replacement ( *"')Attached <br />( ) Additional Unit Add-on ( ) Detached <br /> o.o, <br />Name: Manufacturer /~,~'~? Sections 2 <br />Type of Sidineg.'' ..... Type of Roofing: Square Footage:/~"~O No. of Bedrooms: <br />(~ff'ood ( <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~cup~t: ~ling A~ess:~ ~~ ~ O/ ~o~ No.: <br /> <br />~t Wide: Wff ] ~t ~p~: //~ ~ Acres: Im ~t: Comer: ~ <br /> <br />U~Bou~? ( )Yes ( )No WaerSupply: ( )~v~Well ( )Co~uni~Well <br /> <br />3. CONTRACTOR INFORMATION m 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 :viii 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 /> gl~ction Conffactors 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 />( ) I am an AUTHORIZED REPRESENTATIVE of the pmporty owner or the contractor. <br /> <br />Name: <br /> <br />Mailing Address: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 = <br /> (includes EL, PL, ME connections) <br /> State Surcharge $12.25 = <br /> stmv~ $20.oo= ~2~.. ~_.. <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Reinspection Fee <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 pri~PHONE: ~ <br />SIGNATURE OF APPLICA.~,~_ __ -- ~-- -- ~- DATE: ~ Z 2-- <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />