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~?R CiTY VALIDATION <br />REceiv~By: /ClOt/glo' <br />Zoning Validation: <br />[Date: "~- :~'/ --7? <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 <br /> Sa]em, Oregon 97301 /~x <br /> Phone 588-514'/ ~/_//)/l~ <br /> 8:00anl-4:30pm <br /> 24 HR InSpection Line 588-7904 <br /> FAX 588-7948 ~f~ <br /> MANUFACTURED DWELLING "~ <br /> <br /> FOR CITY USE ONLY <br /> <br />E[ly Setback Requirements: <br /> <br />/of [. ghtS de: /o' <br /> <br />1. JOB DESCRIPTION <br /> <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers~,~'~ ~l Year of t No. of Length t/~ ~idth <br />Name: t"}-O ~ ~-'t' Manufacturer ~ 7 Sections 2-. 4 ~ ' Z. 7; <br />Type of Siding: Type of Roofing: Square Footage: ,/.~ ~ ~ No. of Bedrooms: ,.~ <br />( ,,'~Wood ( .~Comp <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal /~/0 ~-~t~'.~ <br /> <br />2. LOCATION OF INSTALLATION <br />JobAadress' ~g~[{ YO~l~ '~J~' <br /> <br />Section: .~ O Township: ~,g Range: <br />LotWidth: ,~,~ LotDepth: /~*~ Acrvs: <br /> <br />Z .... ~.q, Map: ,.~ ~} ~ <br />Irt. Lot: Comer: <br /> <br />Water Supply: ( ) Private Well ( ) Conununity Well <br /> <br /> Udoan Growth Boundary? ( ~Yes ( ) No ( ~Y'City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and wilt be my own general contractor. I understand that I <br /> must register as a construction contractor if the structure is sotd or offered for sale before or upon completion. If I hire subcontractors. I will hire only <br /> subcontractors registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the <br /> Construction Contractors Board, I will immediately notify Marion County of the name of the contractor. <br /> (~ I am a CONTRACTOR registered with the Slate of Oregon. <br /> BtLsiness I~ amc: . Registration No,: <br /> <br /> along mss: <br /> <br /> 1 am an AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br /> <br /> IMm[ling Address: .~ff,¢~ <br /> <br /> Phone: <br /> <br />4. FEE SCHEDULE <br /> <br /> A. Manufactured PlacementiConnecfions $245.g0 = '~'~- ~ B. Additional Inspectiord <br /> (includes EL, PL, ME connections) (beyond third inspection) <br /> State Surcharge $12.g5 = <br /> State Fee $20.00 = <br /> Z~uin~;~ut~.]~tt;~ 0I appllcaom) $20.00 = <br /> <br /> TOTAL <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 print): ~-~ .~O PHONE: 7 ~'~-7 7 ~t~t <br />SIGNATURE OF APPLICANT: ~ DATE: <br /> <br />MC 15-64 Rev 3/95 <br /> <br /> <br />