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FOR'CITY VALID~ <br />Received'By: ~ ~ <br />Zoning Validation: t/~.~. <br />Date: ~-/~- -~, <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />lVIARIONcoMmJmTvCOUNTY285 ChurchDEVELOPbtENTBUILDINGst. NE - Room CEHTER132INSPECTION FOR CITY USE ONLY <br /> Salem, gon 97 V.Caf ?-O <br /> <br /> PERMIT APPLICATIOI~i:ll0g 60Ui'I'P/ <br /> <br />1. JOB DESCRIPTION <br /> <br /> ( ) Additional Unit Add-on ( ) Detach~ ,,~.~'*~' ~ <br /> <br />Type of Siding: Type o~.J. Roofing: Square Footage: /..~ t~/~ No. of Bedrooms: <br />( ,,,0'~tx~ (~Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( ) Vinyl ( )Metal ~0 7J~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br />() <br /> <br />I am the PROPERT~ OWNER and own, reside in, or will reside in the completed sh~cture and will be my own general contractor. I understand that I <br />must register as a consmmtion conUactor if the smacture is sold or offered for sale before or upon completion. If I hire subeonUactors, I :viii hire only <br />subeonffactors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the <br />Construction Contractom Board, I will immediately notify Marion County of the name of the contractor. <br /> <br />I am a CONTRAC'I~R registered with the State of Oregon. <br /> <br /> / <br />I am an AUTHORIZED R~PR~SENTATIVE of the prope~] owner or the contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured PlacemenffConnections $245.00 <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 <br /> Sta~ Fee J $20.00 <br /> <br />TOTAL <br /> <br />~tS", fro B. Additional Inspection/ <br /> (beyond third inspoetion) <br />/~. ,~ ~.~"" Reinspection Fee <br /> <br />$60.00 <br /> <br /> hereby certify that the above information is cerrcct. 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 />NAMEOPAPPLICANT(pIeasepri~ CaV~O/~I~"~/-~ ~l~A'~'J'l~t2 PHONE: <br />SIGNATURE OF APPLICANT: · '"'- ~ ""' ~ ~ -~r T) r~ DATE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />