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1.F.OR,C ITY VALIDATION] <br /> Rec;ived By: ~ C.. I <br /> Zoning Validation; ~--~../ <br /> Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 <br />Salem, Oregon 97301 <br />8:00am-4:30pm Phone 588-5147 Front: <br /> <br /> 24 HR Inspection Line 588-7904 <br /> FAX 588-7948 ~ <br /> <br />FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br /> Right Side: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLB I~ <br /> <br /> ~'Y~) New Placement Garage or Carport <br /> ( ) Replacement ( ) Attached flIJILDl^t~ ~,_ NTy <br /> ( ) Additional Unit Add-on ( ) Detached, '"~ ¢~/~1 0Pd <br />Dealers Year of No. of I Length Width <br />Name: Manufacturer 2-g7 Se tio.s I, 60 / iq' <br />Type of Siding: Type of Roofing: Square Footage: ~ q0 No. of Bedrooms: ~ <br />(~) Wood (~') Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal / <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile Home P~k Name: Space g: <br /> <br />~cup~t: Mailing Address: Phone No.: <br />Section: ] Township: J ~ R~ge: ~ ~ne: ~ Map: /0 .~ O/CO <br /> <br />Urb~ Gro~ Bounds? ~ Yes ( ) No Water Supply: ( ) ~vate Well ( ) Community 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 /> I Business Name: Registration No.: <br /> Mailing Address: Phone: <br /> <br /> ( ) I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> Name: <br /> <br /> Mailing Address: Phone: <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 />State Fee $20.00 <br />Zoning Surcharge (if applicable) $20.00 <br /> <br />Additional Inspection/ <br />(beyond third inspection) <br />Reinspection Fee <br /> <br />$60.00 = <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 /> <br />NAME OF APPLICANT (please print): Y~/',~ i~ L~ ~ p ~)~ ff'.~/9'~ ~ ~ PHONE: ~// <br />SIGNATURE OF APPLICANT: ~~--~'~ / ~~ DATE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />