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,MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suit~ C <br /> Salem, Oregon 97305 <br /> 8:00 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: ~ Reat:..~_ <br />Left: fi" Righ'c ~r <br />Special: ~ ~ <br /> <br /> MANUFACTURED DWELLING PERMIT APPLICATION <br />1. JOB DESCRIPTION <br /> <br /> RESI))ENTIAL <br /> ~)New Placement . ( )Replacement ( ) Additional Unit Add-on <br /> <br />Typ¢ofSiding: ( )Wood ( )Metal ~Vinyl <br /> <br />Super Good Cents Home ( ) Yes ~0 No (Provide Documentation) <br /> <br /> *FLOOR PLAN REQUIRED* <br /> <br />Garage or Carport <br />( ) Attached tached Height: <br />No. Of Sections: Z Length: ~,/~ Width: ,~.~ Hcight:/t~. <br />TypcofRunfing: ~Comp ( )Steel ( )Metal PitSet:( )Y ~N <br /> <br />Number of Bedrooms: ~_. Existing: Proposed: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> ( ) Mobile Home P~k ( ) Mobile Home Subdivision <br /> <br />I Space It: [ TotalIt Spaces: , , <br />( ) AC I UGB: () N <br />'1 Water Supply: ( ) Private Wail ( ) Community Well ~City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> I tun the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be own general contractor. I understand th~ 1 must <br /> my <br /> register as a construction contractor if the structure is sold or offered for sale before or upon completion. IfI hire subcontractors, I will hire only subcontractors <br /> registered with the Construction Contractors Board. Ill change my mind and do hire a general contractor who is regiat~red with the Constmation Contractors <br /> Board, 1 will immediately noti~ Marion County of the name of the contractor, <br /> <br />I am the AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Busings Name (please print)_ <br /> <br />Mailing AddreSs: <br /> Street: City: Zip: Phone: <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br />B~inass Name (please print): <br /> <br />.Registration It: <br /> <br /> Mailing Address: <br /> Street City: Zip: Phone: Fax: <br /> <br />4. 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 ~ <br /> <br /> (3) State Adminisa'ative Fee 30.00 <br /> (4) Zoning Surcharge, if applicable ~ <br /> <br />B, (1) *Earthquake-Resistant Bracing System (ERB) ~ <br />(2) State Surcharge ~ <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 Reinspectinn <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 />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 /> ,'73 <br />Name of Applicant [Please Print]: <br /> Mailing/).4dress: <br /> /PJ~one: ~"t4J'. ~_J~ _ ~ t_q-~ -0 -- <br />Signatme of Applicant: <br /> MC 15-64 Rev 9/98 "~ <br /> <br /> <br />