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IFOR. CITY VALIDATION! <br />Received By: __ <br /> <br />Zoning Validation: <br /> <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY 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 />iFO__._~R CIT~ US____E_E _ONLY <br />City Setback Requirements: <br /> <br /> Front: Rear: <br /> Left Side: I Right Side: <br /> <br /> (( )~Iew Placement Garage or Carport ~ <br /> b/) Replacement ( ) Attached <br /> ( ) Additional Unit Add-on ( ) Detached <br /> <br />Dealers Year of No. of [Length I Widths,. <br />Name:5"~5 /4t9/~ Manufacturer /~-a~ Sections ~ ~ ¢ <br />Type of Siding: Type of Roofing: Square Footage: [~'~j.~ No. of Bedrooms: ~t~ <br />(//q'~ood ( ~Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Mobile Home Park Name: '" Space #: <br />Occup~t: ~/ Mailing Address: /( Phone No.: / ( <br /> <br />Section: Township: Range: Zone: Map: <br />~tWidth: ~ ~tD~pth: I 3 ~ Acres: ~. ~$~ lmLot: Co.er: <br /> <br />Urb~ Grow~ Bound? ( ) Yes ( ~ Water Supply: ( ~fivate Well ( ) Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br />( ) <br /> <br />I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that ! <br />must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I will hire only <br />subcontractors registered with the Construction Contractors Board. If I 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 /> <br />() <br /> <br />IBusiness Name:/~ ] /* / //,0~ ~ <br /> L,z,O-M ( /n. ll. c4 { 5,".44~ c; TLl'tar-.-"Ilwn r71.£. <br />Registrati°nN°':CC~r'~~4' 993g~ <br />I am ~ AUT~ORIZE~ ~P~SENTATIVE of the pro~ny owner or the contractor. <br /> <br /> Name: ' ~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 = <br />State Fee $20.00 = <br />Zoning Surcharge (if applicable) $20.00 = <br /> <br />$245.00 = B. <br /> <br />TOTAL <br /> <br />RECEIPT #: <br /> <br />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 started within 180 days of issuance <br />or if work is suspended for 180 days. <br /> <br />NAME OF APPLICANT (please print,: DO.,- ~!/'~ t~ 1~_ ~,A'"/O~ Z PHONE: <br /> U ' <br />SIGNATURE OF APPLICANT: DATE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />