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FOR CI~TY VALIDATION MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br /> ,~ ~ COMMUNITY DEVELOPMENT CENTER -- -- -- <br /> v Bvt ~ 285 Church St NE - Room 132 ICity Setback Requirements. <br />Rec~ ed _. __ ' 1 <br /> ,,=,,~nn~J J Salem, Oregon 9730 ~ _ <br />Zoning Validation' -/l~'r 800am430 mPhone5885$~g:~ Front: {0 { Rear: <br /> <br /> MANUFACTURED D a ~W~v~:i~ -- <br /> COMPLETE ALL SECTIONS ITHROUGH4 PERMIT APPLICATION ~P ~ ? ,,,, <br /> MA" " / '?';~ <br /> 1. JOB DESCRIPTION ~lJil ~,H,[O_~/' !flu'r,. <br /> <br />) Additional Unit Add-on ( ) Detached <br />Dealers ~..~.'~/? Year of / e ¢ C No. of ~ng~ Width <br /> <br />T~ nf Siding: Ty~ of R~fing: Square F~tage:~ O No, of Bedmms: ~ <br />W~ ~ Comp <br />Me~ ( ) S~el Pit Set: Energy: <br />Vinyl ( ) Meal <br /> <br />2. LOCATION OF INSTALLATION <br />Job Address: g Tax Account. #:~ Cross Street:[P° YxOL~Fld~ ~:''~ <br /> <br />Mobile Home Park Name: Space #: ~ ~ <br /> <br /> Urban Growth Boundary? ( ) Yes ( ) No Water Supply: ( ) Private Well ( ) Communby Well ~City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( > I am an AUTItORIZED REPRESENTATIVE of the property owner or the co~t~tctctoOr.,~> <br /> <br />Mailing Add. ss: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured PlacemenffConnections $245.00 <br />(Lnclud~s EL, PL, ME connections) <br />Sta~e Surchaege $12.25 <br /> Sta~ Fee $20.00 <br /> Zoning Surcharge ([f~ $20.00 <br /> <br />B. Additional Inspection/ <br /> (beyond third 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 days of issuance <br />or if work is suspended for 180 days. <br />NAMEOFAPPLICANT(pleasepfint):.T~}~M ~1, ${O~.t~/~a . <br />SIGNATURE OF APPLIC ANT: ~~_~~ - - <br />MC 15-64 Rev3/95 ~ <br /> <br /> <br />