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FOR C~TY VALIDATION <br /> <br />MARION COUNTY BUILDING 'INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> <br />FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br /> <br />Let$ide: /~" t Right$ide: /.~' t <br /> <br />co E sEc oNs, m OU H <br /> <br /> 1. JOB DESCRIPTION <br /> <br /> ( ~New Placement o"~.~_"'r~lLOl~:~''v <br /> ( )Replacement (,~Attac'~-,~,-~'' tlVQ iNe_UNTF <br /> ( ) Additional Unit Add-on ( )Detached 'vOP~C~'/O~l <br />Dealers ~?/QI~ ~ Year of I 77 No. of Length Width <br />Name: /:/-,0 t~4'~ Manufaaturer Sections ~ ~.~" ~.~ <br />Type of Siding: Type of Roofing: Square Footage: ,,~ No. of B~rooms: <br />) Metal ( ) Steel Pit Set: Energy: <br />)Vinyl ( ) M,tal ~p ,,~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />( ) I am the PROPERTY OWNER and own, r~side in, or will reside in the completed structure and will b~ my own general contractor. I unde~s~nd that I <br /> <br />4. FEE SCHEDULE <br /> <br />A. MaaufzcalredPlaccmcnt/Conn~Qons $245.00 -- ~*,~'~ ~ <br /> (includes EL, pi, ME connections) <br /> <br />$60.00 = <br /> <br />I hereby ceatify that thc above information is correct. Permits are non-transferrable and expire if work is not ststted within 180 days of issuance <br />or if work ia suspended for 180 days. <br />NAMEOF APPLICANT(please ~ pHONE: 7~'~-77~ --b ~ b ~ <br />SIGNATURE OF APPLICANT: DATE: __ ~ <br /> <br />MC 15-64 Rev3/95 <br /> <br /> <br />