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FOR CITY VALIDATION I MARION COUNTY BUILDING INSPECTION <br />, ~ / / COMMUNITY DEVELOPMENT CENTER ] <br />Received By: ~ ~;~ ff~Xff.~,~t 285 Church St. NE - Room 132 [City Setback Requirements: <br />-/~ ~/ ~,e ~ ] Salem, Oregon 97301 <br />Zoning Validation: ~ } $:00am4:30pm Phone 588-$147 [Front: <br />F~at~. ,~--g5~ ~ ~ q~, I 24 HR Inspection Line 588-'D04 ILeft Side' <br /> <br /> COMPLETE ALL SECTIONS, ' THROUGH 4 PIq~RMIT APPLICATION <br /> <br /> ( v~New Placement Gara~o~ MARION COUNTY <br /> ( ) Replacement (~ Attached <br /> ( ) Additional Unit Add-on ( ) mtach~ BUILDIN6 INSP~TION <br /> Name: ~d/*~.~ Manufacturer ~#/~ Sections ,~ ~ Z$ <br />i Type of Siding: Type of Roofing: Square Footage: ,l~{~O No. of Bedrooms: .~ <br />( v'~Wood ( ~"~mp <br />( ) Metal ( ) Steel Pit Set: Energy: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Property Ownec.~0 ~ ~~ ~ Mailin§ Address: Phone No.:.~'~..~ ,,. ~'3 ~ <br /> Oeeupunt: Mailing Address: Phone No.: <br /> <br />i Section: ,.~ Township: a X Range: ~ ~ Zone: ~ Map: <br />LotWidth: ~.~1 LotDepth: q7 ^=,: Irr. Lot: Comer: ~eeS <br /> <br /> Urban Growth Boundary? ( s~Yes ( ) No Water Supply: ( ) Private Well ( ) Community Well (-~'5~City <br /> <br />3. CONTRACTOR INFO~ON ~ PLEASE INDICATE WHO IS DOING THE WORK <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 I <br />must r~gister as a c, onstru~on contractor if tbc stn~to~ is sold or offered for sale before or upon completion. If I hire subcontractors, I will hi~ only <br />subcontractors registered with the Construction Cont~actors 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 />Mailing Address: <br /> <br />4. FEE SCHEDULE <br /> <br />Phone: <br /> <br />A. Manufactured Placement/Connections <br /> (includes EL, PL, ME counection~) <br /> State Surcharge <br /> <br />$245.oo = ~~'~ B. Additional Inspection/ <br /> (beyond third inspection) <br />$12.25 = /~.,~" Reinspeefion Fee <br />S20.00 = ,..%~. <br />s2o.oo = ~ <br /> <br />TOTAL ~/~ ~ <br />RECEn~r #: ~..~ <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 is suspended for 180 days. ,, <br />NAME OF APPLICANT (please prin0: ~ ¢l~/~g'/~O't~crL~ '~'K}'//~,~ .PHONE: 7~'~?'~'~f,~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />