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FOR CITY VA_LID&TIO~N <br />Rece/_.~ed By: ~~ <br />Zoni~ l,rolidation: ~ <br />IDate: ,~"-~,:~,d~ f~ ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <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 /> MANUFAC;A~;;~~ ~ <br /> PERMIT APPLICI~I$IJI~ - <br /> <br /> FOR CITY USE ONLY ] <br />2ity Setback Requirements: <br /> <br />Front: /p Re~: ID <br />~e: ,~,~ Right Side: ~ ~r.~ <br /> <br /> ( ~j"I%w Placement Garage or~a/po · <br /> ( )Replacement (I,'"5~Attach"~'M'~' MARION COUNTY <br /> ( ) Addifion~ Unit Addmn ( ) Detached 8UILDINGiNSPECTION <br />De.em ~ ~ Ye~ of No. of ] ~ng~ ~ Wide7 <br />N~e: ~ Manufactu~r ~7 S~tions ~ ~g I <br />Type( ~d°f Siding: (Type~comp°f Roofing: Square Footage: ~ ~ No. of B~ms: ~ <br />( ) Me~ ( ) Stol Pit Set: Energy: <br /> <br />2. LOCATION OF INSTALLATION <br />~cup~t: I Mailing Ad&ess: Pho~ No.: <br /> <br />Lot Depth: ~ ~__ Acres: <br /> <br /> ~ Zone: ~ Map: <br /> Lot Width: ..=t_t_t_t_t_t_t_tff~ lrr. Lot: Corner: <br /> <br /> Urban Growth Boundary? ( ~s ( ) No Water Supply: ( ) Private Well ( ) Community Well ( l~ity <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />l am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that I <br />must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will 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 County of the name of the contractor. <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactared PlacemenffConn¢ctthns <br /> (includes EL, PL, ME connections) <br /> State Sumbarge <br /> <br />$245.00 = ~---~'~ '~ B. Additional lnspectioo/ <br /> (beyond third inspection) <br />$12.25 = ~. ~-'~' ReinspeetionFee $60.00 <br /> <br />$20.0o = ~ <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 />  _P.ONE: 7k~'-/qg2~ <br />NAME OF APPLICANT (please print) '~ <br />SIGNATURE OF APPLICANT: ~ I~r~=~1~/~4'''~*''~O'~ _DATE: ~1~/~7 <br />MC 15-64 Rev3P95 <br /> <br /> <br />