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IFOR CITY VALIDATION <br />eceivedBy: __ <br />m~ng~Validafion: <br />ate: <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 Linc 373-4427 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED DWELLING <br /> PERMIT APPLICATION <br /> <br /> FOuR CITY' USE_____ONLY <br />City Setback Requirements: <br /> <br />Front: Rear: <br />Left Side: Right Side: <br /> <br />*Floor Plan Required* <br /> <br />( ) New Placement Garage or Cmport <br />(1/') Replacement ( ) Attached <br />( ) Additional Unit Add-on ( I~ Detached <br />Dealers FA¢~.°&~t ]~llt//~j' Yearof No. of Length / Width) <br />Name: ~.~l.l~ll~Pyt't[&, Manufacturer ~qq7 Sections O~_ ..~Z <br />Type of Siding: Type of Roofing: Square Footage: ]/.~ i No. of Bedrooms: <br />( I,~Wood ( I~Comp <br />( ) Metal ( ) Steel Pit Set: Super Good Cents (~' Yes ( ) No <br />( )Vinyl ( )Metal <br /> *Include <br /> Documentation <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />ISpace#: <br /> <br /> Occupant: 5 ~t~t~ I Maiting Address: / Fhone,~o.: <br /> Section: Township: Range: Zone: Map: <br /> <br /> Lot Width: Lot Depth: Acres: waterslrr-L°l:upply: Comer: <br /> <br /> Urban Growth Boundary? ( )Yes ( )No ( ) Private Well I )Coinmun[tyWell ( )City <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. 1 understand that I <br />must register as a constracfion contractor if the stracture is sold or offered t~r sale before or upon completion. If I hire subcontractors, I wdl hire only <br />subcontractors registered with the Construction Contractors Board. If 1 change my mind and do hire a general contractor who is registered with the <br />Construction Conh'aclors 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 />I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured PlacemendConnections $245.00 = <br /> (includes EL, PL, ME connections) <br /> State Surcharge $12.25 = <br /> State Fee $20.00 - <br /> Zonthg Surcharge (if applicable) $20.00 = <br /> <br />TOTAL <br /> <br />RECEIPT#: <br /> <br />B. Additional Inspection/ <br /> (beyond t hilxl inspection) <br /> Reinsgecdon Fee <br /> <br />$60.~ = <br /> <br />1 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. ' ~ ~ ~-':~J.q~ ~0 <br /> <br />MC 15-~ Rev~6 <br /> <br /> <br />