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i?R CI2~Y VALIDATION <br /> ecei~ed By: ~ <br /> ning Validation: t/ A~_~_ <br /> ate: g, -~/~ '~ 6 <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH, <br /> <br /> 1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMLVN]TY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:301~n Phone 588-5147 <br /> 24 HR Inspection Line 588-7904 <br /> FAX ~8-7948 <br /> <br />'[ ~\~. 5_ ~T~CATION <br /> MARION COUNI ~ <br /> ' ('~2 Ar acheT <br /> BUILDING INSPEC"IO~ D~t~ched <br /> <br />IpFORCITY USE ONLY <br />ity Setback Rcquir~ra~ntS:ightR <br /> font: /~ ! Rear: /.~ / <br /> <br />((~New Placement <br /> Replacement <br /> Additional Unit Add-on <br /> <br /> Dealer <br /> <br />[6()Wood <br />[( )Metal <br />[( ) Vinyl <br /> <br />Type of Roofing: <br />(~ Comp <br />( ) Steel <br /> ) Metal <br /> <br />No. of [ Leng~ J ] Width <br />~ .~/~ <br /> <br />2. LOCATION OF INSTALLATION <br />Sob Address: Tax Account. #: Cross Street: <br />Mobile Home Par~ Name: <br /> <br /> Owner: ~ Mailing Address: <br /> I~x)perty <br />~~~.~Occupant~ ~"~ ~'~Ma~iling Address:~ Map~ ~4~- Phone NO.: <br />UrbanGrowthBoundaty? ( )Yes ( )No LWat~rSupply: ( )FrivateWe[1 ( ) Community Well (~City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ( ) I ara the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that l <br /> <br /> MalhngAddress: I ~ ~ . '~ PhoRe: ~b -97q <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement~2onneetions $245.00 <br /> (includes EL, PL, ME connections) <br /> <br />B. Additional Inspection/ <br /> (beyond thLrd inspection) <br /> <br />$60.00 = <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expir~ if work is not started within 180 days of issuance <br />or if work is suspended for 180 days. /e~ ~ <br />NAME OF APPLICANT (please print,: ~ PHONE: 6q- -I 7qq_ <br />McSIGNATURE1544 I~vOF3/95APPLICANT: ~ DATE:~ <br /> <br /> <br />