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FOR CITY VALIDATION MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> ~ ~ ,n ~ COMMUNITy DEVELOPMENT CENTER <br />Received By: ~ 285 Church St. NE - Room 132 Icity s~tha~k R~q.i~,m~: <br /> - f ~/ ~,/1/ Salem. Oregon 97301 <br />ZoffingV~idafion:, ~ 820~m-423~m Phone 588-5147 IFront: /O I I~: /~ ' <br />Date. ~--~]- ~ ~ ~ ~R l~flon Line 58S-7~ <br /> <br /> Co~TE ~L SE~IONS, 1 ~OUGH 4 PE~T APPLICATION <br /> 1. ~OB DESC~ON <br /> <br />(X) New p]a~me,t Oar~ge I~C~.L.~.~- r~amu~ t, uu,~, <br /> (' ) Replacement ( )~""~' BUILDING INSPEG~ <br /> ( ) Ad~tional U~t Add-on ( ) ~mched <br /> <br />Dealers ~ , Il Ye~of ~,C{ No. of ~ng~ Width <br />T of Siding: <br />~W~d ~y~ofR~fing: SquamF~tage: ~S~ mo. ofB~rooms: 3 <br /> (~ Comp . <br />( ) Me~ (' ) S~el Pit Set: Ener~: <br /> <br />,, <br />ION <br /> <br />2. LOCATION OF INSTALLATION <br />Urban ~o~ B~nd~? ( ) Y~ ( ) No Water Supply: ( ) ~vate Well ( ) Community Well ~ Ci~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ( ) I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general con¢ractor. I understand that I <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placem~ntJConnecfions <br /> (includes EL, PL, M~ connections) <br /> <br />$245.00 = O~'~, g/~ <br />$12.25 = ~ <br />$2o.oo: ...-~. ~ <br /> <br />B. Additional lnspectio~ <br /> (beyond third inspecllon) <br /> Rcinspeetion 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. f~ <br /> <br />MC 15-64 Rev3D5 <br /> <br /> <br />