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FOR CITY VALIDATION <br />Received By: __ <br /> <br />IZ°ning validati°n: I <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 />IFOR CITY USE ONLY <br />LeftFront:City Side:Setback ReqthrememS:ight Rear:R <br /> Side: <br /> <br />( ) New Placement Garage or Caq~ort <br />(~) Replacement ( ) Attached <br />) Additional Unit Add-on ( ~l~ Detached <br />Dealers Year of qo No, of g Length ~ Width <br />Name: Manufacturer Sections <br />Type of Siding: Typ of Roofing: <br />( ~ Wood ( ~Comp Square Footage: No. of Bedrooms: <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> ,ob^dd=,: .t.a4me &V,UeeJtJq_[T xAec°unt-': , to/ <br /> MobileHomeP~kName: ~ ~ I~ ~oO ~ I Space~: ~ <br /> Mailing A~ess' ~n j O ~ {~O~}~o~ No~ ~ ~t~ <br /> Urban ~ Bounds? ( ) Yes ( ~ No Warn Sup~ y: ~vate We ) Commun ty We Cty <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> I am the PROPERTY OWNER and own, reside in, or will reside in the completed stracture and will be my own g~neral contractor. I understand that 1 <br /> must register as a cons~u¢fion contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I ~vill hire only <br /> subcontractors r~giat~red with th~ Constractlon Contractors Board. If I change my mind and do hire a general contractor who is ~egistered with the <br /> Construction Conffactors Board. I will immediately notify Marion County of the name of the contraOor. <br /> <br /> ) 1 am a CONTRACTOR registe~d with the Stat~ of Oregon. <br /> Business Name: Registration No.: <br /> <br /> Mailing Address: Phone: <br /> <br /> ) I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> ~g Address: Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections <br /> (includes EL, PL, ME connections) <br /> Stat~ Surcharge <br /> <br />$245.00 = B. Additional Inspection/ <br /> (beyond third inspection) <br />$12.25 = Reinspectthn Fee <br />$20.00 = <br />$20.00 = <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 /> <br />or if work is suspended for 180 days. <br /> <br />MC 15-64 Rev 3/95 <br /> <br />DATE: <br /> <br /> <br />