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FOR C[T.Y ~.ALIDATION <br />ReCeived By: <br />Zoning Validation: <br />Date: c.~~' <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <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 588-5147 <br /> 24 HR Inspection Line 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED DWELLING <br /> PERMIT APPLICATION <br /> <br /> FOuR CIT~Y USE ONLY <br /> <br />City Setback Requirements: <br /> <br />Front: /D ~ Rear: /~ ~t <br />ILeft Side: /~.-' <br /> <br />(t,,'~ew Placement Garage o al~ort <br />( <br />)Replacement <br />Dealer~ t/nt-CC--~ Year of , No. of ~ng~ <br />Nme: ~ ~. Manuhcmr~ ~ <br />T~e of Siding: T~e of Roofing: Squ~e Footage: <br />( ~W~d ( ~omp <br />( )Vinyl ( )Me~ <br /> <br />2. LOCATION OF INSTALLATION <br /> Job Add . 7~ ,,~ ~'~----/1~/~ ~ ~ [ Tax Account. #: " <br /> <br /> ~eupant: Mailing Address: [ ~on~ No.: <br /> <br /> Secfion:.~p Township: ta~.g Ran~: ,2- ~ Zone: ~ Map: 5 ~-~ <br /> <br /> Urban Growth Boundaly? ( ~)~es ( ) No Water Supply: ( ) Palvate We ( ) Community Well (~'~2ity <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> ( ) i am the PROPERTY OWNER and own, reside in, or will reside in the completed s~ructure and will be my own general contractor. 1 understand that I <br /> must register as a consm~ction contractor if tbe structure is sold or offered for sale before or upon completion. If I him subcontractors, I will hire only <br /> subcontractors registered with tho 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 State of Oregon. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245.00 <br />(in¢lede~ EL, PL, ME connections) <br />State Surcharge $12.25 <br />State Fe~ $20.00 <br />o -o- ,-- -_ a.. s:o.oo <br /> <br />B. Additional Inspection] <br /> (beyond third inspection) ~ _ <br /> Reinspection 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 /> <br />SIGNATUREOFAPPLICANT: ~ DATE: ~rA r <br /> <br />MC 15-64 Rev 3~95 <br /> <br /> <br />