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IFOR CITY, VALIDATION <br /> <br />Zoning ' ' : . .. <br /> <br />Date: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 <br />Salem, Oregon 97301 <br />8:00am4:30pm Phone 588-5147 Front: <br />24 HR Inspection Line 588-79th~ ~ Ixft Side' --- · <br /> vax s~794a } I~ ~'~/"~ C-~ ~ ~- ' .-~ <br /> <br /> PERMIT APPLICAT]~"-.. -- %1111 <br /> b'l~v 13 1996 <br /> <br />FOR CiTY USE ONLY <br /> <br />City Setback Requirements: <br /> <br /> Right Side:~ · <br /> <br />job OESCRn nON 3 <br /> <br />(~5'l~ew Placement ' r O~g~o(~ MARION COUNTY <br />( ) Replacement ('""~c~ BUlLDINGINSPECTiON <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers ~~4~ ~ Year of No. of I L~ngth I Width <br />N~me: Manuf~t~rer <br />Type of_Siding: Type o~f Roofing: Square Footage: No. of Bedrooms: <br />( ~ood ( <br />( ) Metal ( ) Steel Pit Set: i Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~u~t: M~ling Ad~: ~o~ No.: <br /> <br />U~ Gm~ Bo~? (~ ( ) No Water Supply: ( ) ~vam Well ( ) Co--unity We~ ( ~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />I am the PROPERTY OWNER and own, reside in, or will reside in the completed sm~cture and will be my own general contractor. I understand that I <br />must register as a construction contractor if the structure is sold or offered for sale before or upon completion, ff I him subcontractors, I ,.viii hire only <br />subcontractors registered with ~he Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the <br />Consmmtion Contractors Board, I will immediately notify Marion County of the name of the contractor. <br /> <br />I am a CONTRACTOR registered with the Slate of Oregon. <br /> Business Name: ' ~ Registration No.: <br /> <br /> M~ling s: <br />z/, ~v't.,~ ~rt, .~. e:. f,~-'~w, a~,, ~'z~ ~ ~, .ho.e: _~, ~ _, ~, / <br /> <br />I am an AUTHORIZED REPRESENTATIVE of the pmpexty owner or the contractor. <br />INane: ~- <br /> <br />~one: 'z~,¢-7 <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 = <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 = <br /> State Fee A2~/~,, $20.00 = <br /> <br />~4/,5'~ t'O B. Additional Inspection/ <br /> (beyond third inspection) <br /> /~t~' ~n~"~ Reinspection Fee <br /> <br />TOTAL <br /> <br />$60.00 = <br /> <br /> 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 ia suspended for 180 days. ~/<~ ,. /~:) ' <br />NAME OF APPLICANT (please pdnt)- ~/~ ,/.,~' ~.~ PHONE:..~'3--/? / / <br /> <br />SIGNATURE OF APPLICANT: /~ ,~/~ ~ DATE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />