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FOR CITY VALIDATION <br />Received. By: <br />Zoding 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 /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Front: I Rear: <br />Left Sic~: I Right Side: <br /> <br />( ) New Placement Garage or Carport <br /> ( ) Attached <br />~..Replacement ~ Detached <br /> ( )-Additional Unit Add-on <br /> <br />Name: ~'~0~ Manufacturer q~ Sections <br />Type 0f Siding: Type of Roofing: Squar~Footage: /"~("~ No. of Bedrooms: <br />( t.~roo~ ( <br /> <br />2. LOCATION OF INS' ?ALLATION <br /> <br /> ~" Tax Account #' " Cross Street: <br />~u~t: M~ling Ad.ss: ~- ~ No.: <br /> <br />~fion: TowmNp: R~g~: ~n~: Map: <br />~ Wide: ~t ~p~: Ac~: I~. ~t: Cme~ <br /> <br />U~Boun~? ( )Y~ ( )No WamrSupply: ( )~va~WeB ~Co~Well <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING TIlE WORK <br /> , <br /> I am the PROPERTY OWNER and own, reside in, or will re. aide in th~ completed structure and will be my own general conJrnctor. I understand that I <br /> must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontracWrs, I ,sill hire only <br /> subcontractom registered with the Construction Contractors Board. If I change my mind and do hire a general contrac~r 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 fl~ Stat~ of Oregon. <br /> Business Name~'., ~ -- Registration No.: <br /> <br /> ! <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufacaured Placement/Connections <br />(includes EL, PL, ME cormeetions) <br />State Surcharge $12.25 = <br />State Fee $20.00 = <br />Zoning Suwhacge (if applicable) $20.00 = <br /> <br />$245.00 = B. <br /> <br />Additional Inspection/ <br />(beyond third inspection) <br />Reinspecfion Fee <br /> <br />TOTAL <br /> <br />I hereby certify that the above inform~ation is correct. Permj~ are non-transferrable and expire <br />or if work is suspended for 180 days('~ ~ ~V <br />SIGNATURE OF APPLICANT:~~ ~..L~-- -- <br />MC 15-64 Rev 3/95 <br /> <br />if work is not started within 180 days of issuance <br /> <br /> <br />