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MARION COUNTY BUILDING INSPECTION <br /> <br />c .FOR CITY USE ONLY <br /> ity Setback Requirements: <br />I <br /> <br />'FOR CITY VALIDATION <br />Rec¢ivetl By: <br /> <br />Zoning Validation: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br /> 8:00am-4:3Opm Phone 588.5147 <br /> 24 HR Ir~pection Line 588-7904 ~ ~'~/~r~. htSi <br /> <br /> FAX 588-7948 <br /> <br />MANUFACTURED DWELLING <br />PERMIT APPLICATION <br /> <br />1. JOB DESCRIPTION q~0 ~ <br /> <br />( ) Me~ ( ) S~1 Pit Set: E~r~: <br />( )Vinyl .(,, ,),Meal ~ ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~cu~t: M~g A~s: ~o~ No.: <br /> <br />U~ ~ B~n~? ( ~es ( ) fro Wmr Supply: ( ) ~v~ W~ll ( ) Co~uni~ Wall ( ~i~ <br /> <br />3. CONTRACTOR INFORMATION w 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 S°ld or offe~ for sale before or upon completion. If I hire subcontractors, I will hh~ only <br />subcontractors registered with the Construction Contractors Board. If [ change my mind and do hire a general conUactor who is registered with the <br />Construction Contractors Board, I will immediately notify Maxion County of the name of the contractor. <br /> <br />t am a CONTRACTOR registered with the Stat~ of Oregon. <br /> <br /> ISusiness NaWe: -- , t <br /> <br />(,,.4'''~ I am an ALrI'HOR~D REPRESENTATIVE of the prope~y owner or the contractor. <br /> <br />Re~strationNo.: <br /> <br />9'c~ 9 4 D <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 = ~ <br /> (includes EL, PL, ME connections) <br /> state Surct~rge $~2.~ = /,Z,'~5" <br /> State Fee S20.00 = .~, ~'~ <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Reinspection Fee <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 suapended for [80 days. <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />