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FOR CITY VALIDATION <br /> <br />Zoning Validation:/~ ,Be~~7'' <br />Date: ~-/"Y- ~ ~ <br /> <br />COMPLETE <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 City Setback Requirements: <br /> Salem, Oregon 973~_~ [ Rear:. /~ <br /> 8:00am.4:3Opm Phone ~1~/~ ~'~ ~-~ ~dq--~ ~]~Frc~ /O <br /> 24 HR Inspection Line ~.ilPtJ~__ ~,.~'"~.~ L~ ~ V/I ~l~e~t ~N~,~.,~ Right Side: <br /> FAX588-794811~I/~.~v----. ~g d~n fl f ! <br /> MANUFACTURED l~LI~, <br />ALL SECTIONS, l Tl-mOVaH 4 PERMIT APPLICATIOII~'/~ ? ~ <br /> 1. JOB DESCRIPTION MARION COUNTY <br /> II tllR. lO., <br /> <br /> ( ~ew Placement Garage ~-- --J ..... ~ "vor'r'L; I ION <br /> ( )Replacement (~Attached , ~/. ~.. ~ ~ ~~ <br /> ( ) Additional Unit Add-on ( ) De~t~ched ~ ~ .... <br />De. alers/~.ff~'~'~ ~_.~_ ~ Year of No. of I Length I Width <br />Name: t-~:~4~ Manufacturer I ~ Sections ~ ~'~ t ~. g <br />Type o~Siding: Type of Roofing: Square Footage: ~'..~ ~ No. of Bedrooms: ~ <br />( .,'~woed ( ,,-)-Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Occupant: Mailing Address: ~'~ ~'~ Phoue No.: <br /> <br />Section: ~ Township: ~S Range: c~-/-) Zone: ~ Map: <br />~ W~d.:/Z/ ~o, ~:/O ~ A~,: ~. ~ot: ~'~_~ Co~. X/~ S <br />Urban Growth Boundary? (*-"~es ( ) No Water Supply: ( ) Private Well ( ) Community Well <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) <br /> <br />I am lhe PROPERTY OWNER and own, reside in, or will re. side in the completed structure and will be my own general contractor. I understand that I <br />must register as a consm~ciion contractor ff 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 Con~ractors Board. If I change my mind and do hire a general contractor who is registered with the <br />Construction ConUactors Board, I will immediately notify Marion County of the name of the contractor. <br /> <br />( .fi' I am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Business Name: ~ · /. ~ RegisUafion No.: ,,~ ,,~., <br /> <br />I ~ ~ A~O~ ~~A~ of ~ pw~fly owner or ~e con.tot. <br /> <br />Mailing Address: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections S245.00 <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 <br />State Fee $20.00 <br />Zoning Surcharge (if applicable) <br /> <br /> TOTAL <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 suspended for 180 days. <br />NAME OF APPLICANT (please print): ~~ 40/L/~::~ /~,/~ ~ ,~/~,~ PHONE: 7~-- ,"~ ~ <br />SIGNATURE OF APPLICANT: ~ DATE:~~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />