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1FOICATY VALIDATION MARION COUNTY BUILDING INSPECTION ~ FOR CITY USE ONLY <br /> ~ - ~ I COMMUNITY DEVELOPMENT CENTER [ -- -- -- <br /> Received By: iZh,tl'~ d ¢,;/[~---~ I 285 Church St. NE - Room 132 Icity sct~k <br /> - . ~ I Salem, Oregon 97301 I , <br /> Zoning Validation: [ ~ 8:00am-4:30pm Phone 588-5147 [F~ont: <br /> r~,~. ..~ --~.,~t; ~q"'~ [ 24 HR lnspection Line 588-7904 II~ftSide' <br /> ..... ! r [ I FAX 588-7948 <br /> MANUFACTURED DWELLINC]~/~ <br /> PERMlrr APPLICATION <br /> COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> 1. JOE DESCRIPTION Or1 'O I '~gS <br /> <br />Ty~ of Si~ng: ~ of R~g: Sq~ F~tage: /~ No. of Beams: ~ <br />( ~ ( ~omp <br />( ) Metal ( ) Stol Pit Sec E~gy: <br />) Vinyl ( ) M*~ ~ ~. ~. <br /> <br />2. LOCATION OF INSTALLATION <br />~cu~nt: I Mai~ng Ad.ss: [Ph~ No.: <br /> <br /> S*cfion: 3 ~ Township: ~, .~ Range: ~ ~ Zone: ~ Map: R ~ ~ <br /> <br /> Lot Wi,thh: ~.-.~ Lot Depth: t/ ~} ~ Acres: fir. Lot: Corn~: <br /> <br />3. CONTRACTOR INFORMATION ~ PLEASE INDICATE WHO IS DOING TIlE WORK <br /> <br />Registration No.: <br /> <br />Phone: ~n~/t.~'/ 71 ] <br /> <br />Mail'r~g Address: ,,~ ,~f~ ~,.. <br /> <br />4. FEE SCHEDULE <br /> <br />s~45.00 = a.t~a'7. -- B. Additional Inspoztioat <br /> (beyond third hlspeetion) <br />$12.25 = I~, ~..,~' R~inspeetion Fee <br /> <br />$20.00 = ~ b, 7..~_ <br /> <br />$~0.0o = ~ ' <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 (pleas, @rin0: /d~d,~ ~/L¢~O PHONE: 7~'~' ~'~¢ <br />SIGNATURE OF APPLICANT: ~ DAT~: <br /> <br />MC 15-64 Rev3/95 <br /> <br /> <br />