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FOR CITY USE ONLY <br />Received ByL Date: <br />Zoning By: City: <br />Receipt g: Amount: $ <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancastor Dr. NE - Suite C <br /> Salem, Oregon 97305 <br /> 8:00 am - 4:30 pm <br /> 24 hx, Inspection Line 33'3-4427 <br /> FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br />Front: Rear: <br />Left: Right: <br />Special: <br /> <br />MANUFACTURED DWELLING PERMIT APPLICATION <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> ~New Placement ( )Replacement <br /> <br />( ) Additional Unit Add-on <br /> <br />Dealer's Name: 5 ctYt'~'n ~ IA,t~+ Year of Manufacturer: <br /> <br />Typ¢ofSiding: ~Wood ( )Metal ( )Vinyl <br /> <br />Super Good Cents Home ( ) Yes ~.aNo (Provide Documentation) <br />2. LOCATION OF INSTALLATION <br /> <br /> *FLOOR PLAN REQUIRED* <br /> <br />Garage or Carport IOtw/P~- <br />( ) Attached ( ) Detached Height: ' <br />No, OfSections: ~ Length: ~.{.t{! Width:l~'t~ t, Height: <br />TypeofRoofing: 5~0Comp ( )Steel ( )Metal PitSet:( )Y )N <br />Number of Bedrooms: Existing: Proposed: ~ <br /> <br />P~cel Owner'.~.~ ~ ~<~' ""C ~l.. '~ Mailing Address' ~. ~ ~ ~CiW: &~[~, ~ zip: ~ Phone: ~ffq-[~ Z~ <br />( ) Mobile Home P~k ( ) Mobile Home Subdivision } Space ~: Totfl g Spies: <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />1 ara the PROPERTY OWNER and own, reside in, or will reside in 'the completed structure and ~vill be my own general conlxactor. 1 unflem~nd that I must <br />register as a construction contractor if the structure is sold or offered for sale before or upon completion. III hire subcontractors, I will hir~ only subcontractors <br />legiste~ed with the Construction Contractors Board. If I change my mind and do hire a general conlractor who is registered'~ith the Conslmffdon Contractols <br />Board, I will immediately notify Marion County of the name of the contractor. <br /> <br />( ) 1 am thc AUTHORIZED REPRESENTATIVE of the property, owner or the contractor. <br /> Busilless Name (please print) <br /> <br /> Mailing Address: <br /> Street: City: Zip: Phone: <br /> <br />( ) I am a CON'I'RACTOR registered with the Sat~ of Oregon. <br /> Business Name (please print): <br /> <br />Registration #: <br /> <br /> Mailing Address: <br /> Sneer City: Zip: Phone: Fax: <br /> <br />FEES <br /> <br />A. (1) Manufactured Placement / Connections <br /> (includes EL, PL, ME connections & 30 feet <br /> each of sewer and water lines): $ 305.00 <br /> (2) State Surcharge 1 ~ o~ <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 />$0c~-- $ IZ't7/.a <br /> <br />$ <br /> <br />$ <br />$ <br /> <br /> $ <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 <br />issuance or if work is suspended for 180 days. <br /> <br />Name of Applicant [Ple~c erintl:__~[ , ~,~[ca:5 ~,'~ :TV., <br />MC 15'64 Rev 9/98 ' t <br /> <br /> <br />