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r <br />FOR CITY VALIDATION <br />Recefv~e'c~ By: __ <br />Zoning Validation: <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 58~.5147 <br /> 24 HR Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED DWELLING <br /> PERMIT APPLICATION <br /> <br />ICity Setback Requirements: ~ <br /> Front: Rear: <br /> Left Side: Right Side: <br /> <br />FOR CITY USE ONLY <br /> <br />( ) New Placement Garage or Carport <br />(~ Replacement ( ) Attached <br />( ) Additional Unit Add-on ( ) Detached <br />Name: ~L0~t~ ~ Manufacturer q"~ No. of <br />Type fSiding: Type fRoofing: <br />(~ood (~Comp Square Footage: f~ ~5 No. of Bedrooms: <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />2. LOCAT~O::~?j,~.I~STALLATION r~ ctA:'0/0d~ iff_., c/700 ~. <br /> <br /> Mobile ltome Park Name: I Space g: <br /> <br />PropetlyOwner: ~O{2~--~r~ ~{~:g~ MailthgAddress: ~'~)~:~l ~[~O-JL~,~i~°neN°':('l~'~) ~ <br />Scion: . ~ Townshlp:we. ~R~ge:/~. ~ Zone: 0_~ Map: ~ ['~ ~5 <br /> <br />~ Wide: ~t~: /Acr~: 3~ lm~t: ~ Come~ <br /> <br />Urban Gm~ B~nd~? ( ) Y~ ~No Wat~ Supply: ( ~vate Well ( ) ~mmuni~ Well ( ) Ci~ <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> I am the PROPERTY OWNER and own, [r~idc in]or will reside in the completed structure and will be my own general contractor. I understand that I <br /> must register as a constxuction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I qdll hire only <br /> <br /> Mailing Address: <br /> <br />J~ I am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br />Registration No.: <br /> <br />Mailing Add.ss: <br /> <br />4. FEE SCHEDULE <br /> <br />TOTAL <br /> <br />RECEIPT #: <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Reinspection Fee <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 />or if work is suspended for 180 days. <br />NAME OF APPLICANT (please pnm) t~ 0 ~ t <br /> <br />MC 15-64 Revg/95 <br /> <br /> <br />