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0..R~ ~ALIDATIONI MAPdONcCoO U D INsS~PECTION [ FOR CITY USE ONLY <br />Received By' ,~ I 285 Church St. NE - Room City Setback Requiremenls: <br /> <br /> 8:00am4:30pmPhone ront: /~ iRear: /~-' -- Salem, Oregon97301 <br /> <br />Date: ..-ff-/~-f'~ [ 2nm~I~specti°nLine~l~jt'~l~,~Y'/~f~lL~f~si&: ,,~--- ~i~tSid~:~- <br /> MANUFACTURED DWELL~ "/~/"~X <br /> ¢OMPLm'~^~S~CT~ONS, IT~gOUaH4 PERMITAPPLIC~/~D~']/;,~[ ~0b~ (~/f/ ~11 1. JOB DESCRIPTION O/*~ ,,,oeot OIt. ~ ~ <br /> <br />( ) Replacement <br />( ) Additional Unit Add-on <br />Dealers ~ ~/-.0~'/~ Year of No. of Length Width <br />Name:~,~..~l~..' Manufacturer ! ~ 7 Sections <br />Type of Siding: Type of Roofing: Square Footage: <br /> <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~0 <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Lot Width: ~-~ fir. Lot: Come~: <br /> <br />Township: F ~ Range: <br />Lot Depth: ~ Acres: <br /> <br />( ) Community Well ( ~'~ity <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 th~ completed structure and will be my own general contractor. [ understand that I <br /> must register ~s a construction contractor if the shmcmre is sold or offered for sale before or upon completion, ff I hire subcontractors, t will hire only <br /> <br /> (~ff lam an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br /> Ma g ddm : .~ Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections <br /> (includes EL. PL. ME connections) <br /> State Surcharge <br /> <br />I;245.0o = ~.-q¢~' ~ B. Additional Inspection/ <br /> (beyond thi~ inspection) <br /> <br />$60.00 <br /> <br />I hereby certify that the above information is correct. Permils ate non-transferrable and expire if work is not star,ed within 180 days of issuance <br />or if work is suspended for 180 days. · <br />NAME OF APPLICANT (please p~ PHONE: "/"~/"7~ ~ <br />SIGNATUREOFAPPLICANT: ~~ I DATE:~7~_- <br /> <br />MC 15-64 Rev3/95 <br /> <br /> <br />