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..................................... ] MARION COUNTY BUILDING INSPECTION <br /> FQRCITYUS~ONLY_ ,:~ ,;.,.~ I COMMUNITY DEVELOPMENT CENTER <br /> Received B ~fYt~..c~-~ Date' /~/7-7~ <br /> ~n,ng By: ~ . Cl~:~~ (~[~gi~a~m Oregon 97305 <br /> Re~ipt ~: ~/~ Amount: $~fi ~/~ ) ~, 4:30 pm <br />................................. ~, [ '24 hr~i~n Line 373-4427 <br /> ~D ~ ~ ~0~q~ ~588-7948 <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br />Front: J~ / Rear: fS~ / <br />LeR: ~7~ / Right: /'~7-'~--_ <br />Soee.'ah <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> ( ) New Placement (~Replacement <br /> <br />MANUFAC~Ji]~D~/ifLING PERMIT APPLICATION <br /> BUILDING IN.~PKCT!O~! ~'-.7]d~/ *FLOOR PLAN REQUIRED* <br /> Garage or ~ <br /> ( ) Additional Unit Add-on ~Attaebed ( ) Detached Height: /~.S <br /> No. OfSections: O~. Length:?~/~, ~')Width: $:~'1 Height:t2' <br /> <br />Dealer's Name~'jlj~t ~/]~5.~ Year of Manufacturer: <br />Type of Siding: (~.Wood ( ) Metal ( ) Vinyl <br /> <br /> TypeofRoofing: (34Comp ( )Steel ( )Metal PitSet:( )Y (~N <br />Super Good Cents Home (~Yes ( ) No (Provide Documentation) Number of Bedrooms: Existing: ~.~ Proposed: ~ <br />2. LOCATION OF INSTALLATION <br /> <br />(){lVlobile Honle Park ()Mobile Home Subdivisio, ~,~3.~{.~'~- ./~/~ ] Space #: ~ / ,ora. <br /> <br />V ope, ocato : 160..%0 0a..Z0' 4.q,a:2qq-br O [WaterS.pply: () Private Well ()CommunityWell 'City <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) 1 am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I undemtand that I must <br /> <br /> - ' Ci~: · - ' Zip: P~o~e: <br /> <br />() <br /> <br />I ara a CONTRACTOR n~gistered with the State of Oregon. <br />Business Name (please print): <br /> <br />Registration g: <br /> <br /> Mailing Address: <br /> Street City: Zip: Phone: Fax: <br /> <br />4. FEES <br /> <br />A. (1) Manufactured Placement / Connections <br /> (includes EL, PL, ME connections & 30 feet <br /> each of sewer and water lines): <br /> (2) State Surcharge <br /> <br />$ 305.00 <br /> 15.25 <br /> <br /> (3) State Administrative Fee 30.00 <br /> (4) r.~,.,,mg-~urcnarge, ~ cq,v ..... le ~.,,,. .... <br /> ,~/. ~o <br />B. (1) *Earthquake-Resistant Bracing System (ERB) ~ S5.09 <br />(2) State Surcharge '4z25 <br />(3) State Administrative Fee 20.09 <br /> <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 />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 /> <br />