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leO~R CI?Y VAL!DATION <br />Received By: <br /> <br />Zoning Validation: <br />Date: ?/2-- ~ <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br /> 1. JOB DESCRIPTION <br /> <br />MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St. NE - Room 132 2ity Setback Requirements: <br />Salem, Oregon 97301 <br /> <br /> 24 HR Inspection Line 58S.7904 <br /> FAXSSS.794S IllJd~ ~.~ ~ " - '" <br /> MANUFACTURED DWELLIi~a <br /> PERMIT APPLICATION <br /> <br /> Garage or arport <br />((~qcw) ReplacementPlacement ( ~.Atta~he~~ <br />( ) Additional Unit Add-on ( ) Detached <br />Dealers'~'tl~/~/ttk~ Year of ~ No. of ~ ~ngth Wid~ <br />Name: ~ M~ufacturer ~b S~tions ~ ¢ ~ ~ 7 <br />Typ~ Siding: T~eof oofing: <br /> -- ~p Square Foo~ge: ]/~ No. of BeSoms: <br />( <br /> ( <br />( ) Me~ ( ) Stol Pit Set: En~gy: <br />( )V~yl ( )Metal ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Mobile Home Park Name: <br /> Space#: <br /> <br /> ~ M~ilin~ Address' I~0~ <br /> Occupant: ] Mailing Address: <br /> <br />~o.e ~o.: <br /> <br />Phone No.: <br /> <br /> Lot Width: ~ Lot Depth: ,,/~ ~:~ Acres: In. Lot: Comer: <br /> Utban Growth Boundary? (~'~Yes ( )No Wat~rSupply: ( )FrivateWeli ( )Commu~fityWall (l.O"~ity <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 structure and will be my own general contractor. I understand that I ] <br /> must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If I hire subcontractors, I '.viii hire only <br /> / <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 /> <br /> ('"Y' I am a CONTR&CTOR registered with the State of Oregon. <br /> <br />Phone: <br /> <br />I 0an an AUTHORIZED REPRESENTATIVE of the progeny owner or the contractor. <br />Ma ling Address: ... ~ /~.¢/~ <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement~Conneclions $245.00 <br />(includes EL, ]FL, ME connections) <br />State Surcharge $12,25 <br /> <br />B. Additional Inspection/ <br /> (beyond third inspection) <br /> Reinspection Fee <br /> <br />$60.00 = <br /> <br />MC 15-64 Rev3t95 <br /> <br />NAMEOFAPPLICANT(pleaseprint): ~/~"'~ ¢~t~'¢ ~ <br />SIGNATURE OF APPLICANT: ~ <br /> <br /> State Fee ~ $20.00 <br /> TOTAL <br /> <br />or if work is suspended for 180 days. <br /> <br /> <br />