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FOR C.~T.Y VALIDATION MARION COUNTY BUILDING INSPECTION <br />  COMMUNITY DEVELOPMENT CENTER <br /> Rbcei~g~i l~y: 285 Church St. NE - Room 132 <br /> <br />IZoning Validation: /5~ Salem, Oregon 97301 <br /> <br /> 0 8:00am-4:30pm Phone 588-5147 <br />[Date: ~-~/-~ -~ 24 HR Inspection Line S88-7904 <br /> ~ /~.,~~t, FAX 588-7948 ~ <br /> ~t/}~, MANUFACTURED DWELLING~,~,§, <br /> COMPLETE ALL SECTIONS, ! THROUGH 4 PERMIT APPLICATION <br /> <br />FOR CITY USE ONLY <br /> <br />~ity Setback Requirements: <br /> <br />1. JOB DESCRIPTION <br /> <br />( ~New Placement (~t~ <br />( ) Repla~nt <br />( ) Additlon~ Unit Add-on ( ) Detached <br />D~e~ ~ Year of No. of ~ngth Width <br />N~e: ~~ Manufacturer t~ Sections <br /> ( ~omp <br />( ) Metal ( ) Stol Pit Set: Eries: <br />( )Vinyl ( )Metal ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />O<upant: Mailing Address: Phone No.: <br /> <br /> Width: ~ / Lot Depth: jj/ Acres: ~. Lot: ~ ~0 <br />U~G~w~Bound~? ( ~es ( )No IWa~rSupPlY: ( )~va~Well ( )Co~unityW~ll ( ~ity <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 srdd or offered for sale before or upon completion. If I hire subconh-actors, I ':all[ hire only <br /> subcontractors registered with the Consttuctlon Contractors Board. If t 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 /> (,~ [ am a CONTRACTOR registered with the State of Oregon. <br /> <br /> Mai ' g s: <br /> <br /> (~'~ I am an AUTHORIZED REPRESENTATIVE of the progeay owner or the contractor. <br /> <br />Ma ng Address: <br /> <br />Phone: 7b~ -77 <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 <br />(includes EL. PL. ME conn~edons) <br />Stat~ Surcharge $12.25 <br />Stat~ Fee $20.00 <br /> <br /> TOTAL <br /> <br />B. Additional Inspection/ <br /> (beyond th[rd inspection) <br /> ReLnspection Fee <br /> <br />$60.00 = <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 /> <br />SIGNATURE OF APPLICANT: 1. ..... ,t Or'~-a-'a'''~ DATE: b ]'-a;~ q~:~ <br /> <br />MC 15-64 Rev 3~95 <br /> <br /> <br />