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FOR CITY VALIDATION I MARION COUNTY BUILDING INSPECTION <br />  COMMUNITY DEVELOPMENT CENTER <br />Received By: ~ 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br />Zoning Validation: '~{~ - I 8:00am-4:30pm Phone 588-5147 <br />D~= ~tn0/~ I 24 fir Impection Line 588-7904 <br /> FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br /> <br />E~ /b-/ <br /> <br />RightSid¢: /~1~ / <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br /> 1. JOB DESCRIPTION - <br /> <br /> ( ~'~NewPlacement Gar~ge0i~.o_~ MARION COUNTY <br /> ( )Replacement ( eDAttachedBUILDING INSPECTION <br /> ( ) Additional Unit Add-on ( ) Detached <br /> <br />Dealers /At~,r ~ Year of No, of Length Width <br />Name: ~.1 ~',,~L~ ~ Manufacturer ~b Sections ~.. <br />Tylx~ of Siding: Type of Roofing: Square Footoge: <br />( .'~Wood ( ~omp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal '/~0 <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Urban Growth Boundary? ( ~J'Ycs ( ) No <br /> <br />Irt. Lot: ~ <br />Water Supply: ( ) Private Well ( ) Conununity Well <br /> <br />(~City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) 1 am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own g~neral contractor. I understand that I <br /> <br />( ,'~ I am an AUTHORIZED REPRESENTATIVE of thc property owner or the contractor. <br /> <br /> Ma ling Address: ..~,~ &~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 <br />(includes EL, PL, ME conn<tions) <br />State Surcherge $12.25 <br /> <br />999 7 <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Rcinspection 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 />SIGNATUP~E OF APPLICANT: ~ -~'~'~~ DATE: <br /> / <br />MC 15-64 Rcv3t95 <br /> <br /> <br />