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FOR CITY USE ONLY <br />Received By:. Date: <br />Zoning By: City:_ <br />Receipt#: Amount: $ <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br /> g:00 am- 4:30 pm <br /> 24 hr. Inspection Line 373-4427 <br /> FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br />Front: Rear: <br />Left: Right:. <br />Special: <br /> <br />1. JOB DESCRIPTION <br /> <br />MANUFACTURED DWELLING PERMIT APPLICATION <br /> *FLOOR PLAN REQUIRED* <br /> <br />RESIDENTIAL <br />( ) New Placement ~Replacement ( ) Additional Unit Add-on <br />Dealer'sName:0~Vl~f/'O't ~'~OtM~$ Year&Manufacturer: ~ <br />Type of Siding: {~Wood ( ) Metal ( ) Vinyl <br /> <br />Super Good Cents Home ~Yas ( ) No (Provide Documentation) <br /> <br />Garage or Carport <br />( ) Attached ( ) Detached Height: <br />No. OfScctions: t~ Length: ~,~' width:oO~7/ H¢ight/qt <br />TypeofRoofing: ( )Comp ( )Steel ( )Metal PitSet:( )Y ( )N <br /> <br />Number of Bedrooms: Existing: Proposed: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> City: <br /> <br />Map: Zone: <br /> <br />( )SF <br /> <br />Space #: <br /> <br /> Zip: Phone: <br /> <br />Total g Spaces: <br /> <br /> I <br /> Parcel Size: <br /> ( ) AC ] UGB: ()Y () <br /> N <br /> <br /> Property Locator: Parcel #: [ Water Supply: ( ) Private Well ( ) Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) 1 am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor, l understand that I must <br /> register as a construction contractor if the structure is sold or offered for sale before or upon completion, lfl hire subcontractors, 1 will hire only subcontractors <br /> registored with the Construction Contractors Board. lfl change my mind and do hire a general contractor who is regislered with the Construction Contractors <br /> Board, 1 will immediately notify Marion County of thc name of the contractor. <br /> <br /> 1 am the AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> Business Name (please print)_ <br /> <br /> Mailing Addrass: <br /> Street: City: Zip: Phone: <br /> <br /> ~ ~ a registered with the of Oregoq.:.. <br /> IBusiness Name (pleas~ print): CONTRACTOR~ tx~..,- &O State -L ~o'q~t/~'t! f0405~.~ Registration#: <br /> <br /> - gtreet ' Ciiy:' -' ~ib: Phone:' ' <br /> <br />4. FEES <br /> <br />A. (1) Manufactured Placement / Connections <br /> (includes EL, PL, ME connections & 30 feet <br /> each &sewer and water lines): <br /> (2) State Sumharge <br /> <br />$ 305,00 <br /> 15.25 <br /> <br />(3) State Administrative Fee 30.00 <br />(4) Zoning Surcharge, if applicable 30.00 <br /> <br />B. (1) *Earthquake-Resistant Bracing System (ERB) $ 85.00 <br />(2) State Surcharge 4.25 <br />(3) State Administrative Fee 30.00 <br /> * This fee is only charged when the ERB system is not <br /> part of the original manufactured dwelling installation. <br /> <br />C, Miscellaneous Fees <br /> (1) Additional Inspection or Reinspection <br /> ~ $60/per inspection <br /> [Assessed for inspections beyond the third <br /> Inspection] <br /> (2) Investigation Fee ~ $305.00 <br /> (4) Other Inspections ~ $50 per inspection <br /> <br />TOTAL <br /> <br />$ <br /> <br />$ <br />$ <br /> <br /> $ <br /> <br />hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of <br />issuance or if work is suspended for 180 days. <br /> <br /> Phone:~ ~l.."-r'] ~'-.~'f~o~--~jlr---.~ - <br />Signature of Applicant: ~1~ <br /> <br /> <br />