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I~O,R CITY VALIDATION <br />[ReceiVed By: <br /> n <br />Zoning Validtttio: <br /> <br />COMPLETE AL~ SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> I <br /> 285 Church St. NE - Room 132 ICily Selback Requirements: <br /> Salem, Oregon 97301 <br /> I <br /> Front: I Rear: g <br /> 8:00am-4:30pm Phone SSS-5147 __ ,--~ o/1~ ~'~ <br /> 24HgIns@ectionLhle~$$-7904 K'"~"~~ /~i~ ~ /~l~tlght Side: <br /> FAx IlL} '-'I"' <br /> MANUFACTURED OWELLINC~( ~ . <br /> PERMIT APPLICATION ~.~ ?,! , ~ <br /> <br />1. JOB DESCRIPTION <br /> <br /> (~) New Placement Garage o~ ~S~z~;U I tu'~ <br /> ( ) Replacement (y0 A.aeh~T BDILDIN$ <br /> ( ) Additional Unit Add~n ( ) ~tached <br /> <br />Type of Siding: T~ofR~fing: Squam F°°tage: [~0 No. of Bedrooms: 3 <br />(~) W~d ( Comp <br />( ) Me~ ( ) Stol Pit Set: Ene~: <br /> <br />( )Vinyl ( )Me~ 8~0, <br /> <br />Irr. Lot: ~O <br /> ( ) Private Well ( ) Conmaunity Well (~ City <br /> <br />3. CONTRACTOR INFORMATION I PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Plac~m¢ nt/Connections <br /> (includes EL, PL, ME connections) <br /> State Surcharge <br /> Stat~ Fee <br /> <br />$245.00= ~,~.,,--0 B. Additionallnspecfion/ <br /> (beyond third inspection) <br />$12.25 = /rog' °~'~ Reinspection Fee <br />$2o.oo = ~. ~ <br /> <br />$60.00 = <br /> <br />or if work is suspended for 180 days. <br />NAME OF APPLICANT (please print): <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 /> PHONE: 7 q-* <br /> <br />SIGNATURE OF APPLICANT: <br />MC 15-64 Rev 3/95 <br /> <br /> <br />