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MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> <br />FOR CYgY VALIDATION <br /> <br />Zoning Validation: ~ , <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St, NE - Room 132 2ity Setback Rcquircm~ate: <br /> Salem, Oregon 97301 <br /> 8:00am-4:30~m Phone 588-5147 C~x r---.. Front: /t9 ! Rear: /~.~ / <br /> 24 HR Inspection Line 588-7904 <br /> FAX588-7948 t~a~ [L~} ~g ~/F'~f'~d -- '-'-~ <br /> <br /> PERMIT APPLICATION <br /> <br />1. JOB DESCRIPTION "~ ~0- "'1 I ~ c,~g~ o~'~_ BUILDING INSPECTION <br />( ) Replaeemem (~ A~c~ <br />( ) Additional Unit Add-on ( ) Demch~ <br />~ ~ Y~of ~, No. of ~ngth ~ , Wid~ <br />~ of Si&~: Ty~ of Roofing: <br /> ?)Wood ~) Comp Squm Foo~ge: <br /> <br /> ( ) Vinyl ( ) <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Job Ad.ess: <br /> <br />Mobile Home Park Nme: <br /> <br />ccount. #: q ~"'- 3/ <br /> <br />Mailing Address: <br /> <br />( ) Yes ( ) No Water Supply: ( ) Private Well ( ) Community Well ~) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ) I am the PROPERTY OWNER and own, r~side in, or will reside in the completed stmcmm and will be my own general contractor, l understand that I <br /> <br />Reg~staation No.: 0 <br /> <br /> Mailing <br /> <br />4. FEE SCHEDULE <br /> <br />B. Additional lnsl~cfiord <br /> (beyond thLrd inspection) <br /> Reinspe~ion Fee <br /> <br />$60.~0 = <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 />or if work is suspended for 180 days. <br />NAMEOFAPPLICANT(pIeas~print): ~lO l~.~3 ?HONE:'7~e-7?qq <br />SIGNATURE OF APPLICANT: [J]~-,~ ~.._ DATE: ~_ ~'~t' ~qt <br />MC 15-64 Rev 3/95 <br /> <br /> <br />