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I~OR C, ITY ~TION <br />Receiv~,d By: <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> COMIvlIJNITY 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 />PERMIT APPLICATION <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Right Side: <br /> <br /> ( ) New Placement Garage or Carport ]~0~ <br /> ( ) Addi~onal Unit Add-on ( ) ~h~ <br /> <br />Ty~ of Siding: ~e of R~fing: Squ~e F~m~: /~ No. of B~r~: <br />~ W~d <br />( ) Meal ( ) Stol Pit Set: Energy: <br /> <br />1. JOB DESCRIPTION <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile Home Pa~k Name: <br /> <br />Urban Growth Boundary? (~¥es ( ) No <br /> <br />[ Tax Account, g: ~t~"/~,~ ~' ] Cross Street: ~.~'~0 <br /> <br /> ~.~t: O~3 Comer: ~ <br /> Water Supply: ( ) ~vag Well ( ) Co~i~ Well ~iry <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> I am th~ PROPERTY OWNER and own, reside in, or will reside in th~ completed structure and will be my own general contractor. I understand that I <br /> must register as a construction contractor if ti~ structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only <br /> subcontraetor~ registered with the Construction Contractors Board. If l 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 /> Business Nam=: R~gistratlon No.: <br /> <br /> Mailing Address: Phone: <br /> <br /> ) I am an AUTHORIZED REPRESENTATIVE of tbe pwpc~y owner or the contractor. <br /> ~ng Address: Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 = ~f dO <br />(includes EL, PL, ME mmnections) ~ ~ <br />State Sureharge $12.25 = / ' <br />State Fee $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 statsed withth 180 days of issuance <br />or if work is suspended for 180 days. ~ <br /> <br />MC 15~4 Rev3~95 <br /> <br /> <br />