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MARION COUNTY BUILDING INSPECTION <br /> <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Salem, Oregon 97301 <br /> 8:00am-4:30pm Phone 588-5147 <br /> 24 HR Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br />MANUFACTURED DWELLING <br /> <br /> FOR CITY USE ONLY <br /> <br />2ity Setback Requirements: <br /> <br />COMPLETE ALL1. JoBSECTIONS' ' THROUGH 4... DESCRIPTION PERMIT APPLICATION [~A¥~ <br /> <br /> ([~ew Placement Garage o~c~o.~ MARIOI~ COUNTY <br /> ( ) Replacement ("'~tt~ch4"~ BUILDING INSPECTION <br /> ( ) Additional Unit Add-on ( ) Detached <br /> <br />Dealers ~OJ{/'~_~l~ Year of No. of Length Wid~ <br /> ( ~mp <br />) Metal ( ) 8t~l Pit ~et: Energy: <br />)Vinyl ( )Me~ ~ ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> Job Address' ~qtl ._~/~l~j~/~'~'~O ~ <br /> <br /> I Mailingnd~ess:~al g~O_ ~' I PhoneNo' <br /> <br /> Urban Growth Boundary? ( ~)"~s ( ) No Water Supply: ( ) Private Well ( ) Community Wnll (l~j~tty <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WItO IS DOING THE WORK <br /> <br /> I am the PROPERTY OWNER and own. reside in, or will reside in the completed structure and wig be my own general contractor. I understand that I <br /> must register as a construction contractor if the structure is sold or offered for snle before or upon completion. If I hire subcontractors, I ','rill hire only <br /> subcontractors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the <br /> Construction Contractors Board, I will immediately notify Marion Courtly of the name of the contractor. <br /> <br /> I am a CONTRACTOR registexed with tba Stat~ of Oregon. <br /> <br />($~1 am an AUTHORIZED REPRES' ENTATI-VE of the p~operty owner'or the con/Iactor. <br /> <br />Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />(includes EL, PL, ME connections) <br />State Sureharg~ <br />State Fee <br />Zoning Surcharge (if applicable) <br /> <br /> TOTAL <br /> <br /> (beyond third inspection) <br />$12.25 = ~ ReinspectlonFee $60.00 = ~ <br /> <br />I hereby certify that the above information is correct. Permits am non-transferrable and expire if work is not started within 180 days of issuance <br />or if work is suspended for 180 days. <br />NAMEOF APPLICANT (please pfin~ .PHONE..~'"'/~'~' ] $ "'~ ~/~ ~'~.~ <br />SIGNATURE OF APPLICANT: DATE: ~ <br /> <br />MC 15-64 Rev3/95 <br /> <br /> <br />