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IFOR'CIT.Y V mSTION <br /> zRo~-~TdvaBl~2ti~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> 1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT~C ER <br /> 285 Church St. NE - Rooom ~J~ ~'~(~t/ <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone $ <br /> 24 HR Inspeeti°n Line 5l{~n~ ' <br /> FAX 588-7948- nO I/ <br /> <br /> PERMIT APPLIC~/~. /a /? /g~ <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />( t-~ew Placement <br /> Gara Carport ~ <br />Dealers ,~'9 4 ~ Year of ! No. of Length <br />Name: ~t~ Manufacturer 97 Sections ~.- <br />(~d Type~Roofing: Square Footage: t~ No. of Bedrooms: <br /> ( ~'3 Comp <br />( )Vinyl ( ) Metal ~O e.~ ,~ag, ~_.~, <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Mobile Home Park Name: x Space #: <br /> <br /> PtopeltyOwner: ~J~-~le~ ~ -- I MailingAddrass: ~_~':_ '~/~ ~'7-~ IPhoneNo' - <br /> ~cupaut: I Ma <br /> <br /> ~ Wide: ~f ~t D~: /07 A~es: Im~t: <br /> Ut~n ~ Bound? ( ~es ( ) No Water Supply: ( ) ~vate W~ll ( ) Co--unity Well ( ~i~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) t am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor, l und~rstadd that I <br /> <br />4. FEE SCHEDULE <br /> <br />$245.00 = <br /> <br />$12.25 <br />$20.00 <br /> <br />B, Additional Inspection/ <br /> (beyond tMrd inspection) <br /> Reinspection 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 day s of issuance <br />or if work is suspended for I80 days. ~ ~ .~ <br />HAMEOF APPLICANT (please ~~f PHONE: ~7' '--7~ .~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />