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FOR CITY VALIDATION MARION COUNTY BUILDING INSPECTION <br /> -~ L-"t ~' ,,-~,~ f ~ / ~. COMMUNITY DEVELOPMENT CENTER <br /> Received By: ,,_.,-fa/ o~- /'-m nna ~]/[t~---~ 285 Church St. NE - Room 132 <br /> <br /> · - i ~/~ / Salem, Oregon 97301 <br /> Zoning Validation: ' "g"/ I 8t00am.4:30pm Phone 588-5147 <br /> mr,.. / 24 HR lnspection Line 588.7904 <br />I ..... L'~ r . ,, I FAX 588.7948 <br /> MANUFACTURED DWELLING <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br />COMPLETE ALL SECTIONS. 1 THROUGH 4 PERMIT APPLICATION <br /> 1. JOB DESCRIPTION ~ '(~0-'] ~ D <br /> <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers ~ I,. Year of I No. of Length Width <br />Name: ¢~' ~ tg41W~ Manufacturer 97 Sections 2 ~1~ <br />Type of Siding: Type of Roofing: Square Footage: ~.~ 0 0 No. of Bedrooms: <br />( t.4"~Vodd ( ~Y'/~omp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal ~0 <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />ITax AccounL#: <br /> <br />Phone NO,: <br /> <br />Lot Width:,.~.~ ' <br /> <br /> Township: ~,~ R~nge: ~.~ 1~ Zone: lll~l~ Map; ,,~ 0 ~ <br /> Lot D~: ~ ~ t Acres: Im ~t: Com~: <br /> <br />3. CONT~CTOR ~FO~ATION ~ PLEASE INDICATE WHO ~ DO~G T~ WO~ <br /> Cons~cfion Con~actom Bo~, I will immediately notify M~on County of the name of ~e contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured P]acemen tic o nnections $245.00 <br />(includes EL, PL, ME connections) <br />State Surcharge $12.25 <br />State Fee $20.00 <br />Zoning Somharge (if applic ab_l~ $20,00 <br /> <br /> TOTAL <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Reinspecfion Fee $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 (pthase t~ PHONE:~ 7~--2~ 7 <br /> <br />SIGNATURE OF APPLICANT: DATE:~~ <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />