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IIR CIV VALIDATIQN <br />!~ved By: ~ <br />o~ing Validation:~ __~--~ <br />ate: ~ -/~ ~:;~.~ <br /> <br /> COMPLETE ALL S~ONS, 1 T~OUGH 4 <br /> <br />1. JO,B 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 588-790~t ~ ~ ~ ~ <br /> FAX 588-7948 Ill I II~--I I-* I~a II~ <br /> <br /> PERMIT APPLICATI~ J U ~ 2 3-~9-q? <br /> <br /> FOR CITY USE ONLY <br /> <br />City Setback Requirements: <br /> <br /> ( KNew Placement~ara~e <br /> Gara eor arport MARION COUNTY <br /> ( ) Replacement (~"~Atta~,,.. BUILDING iNSPECTION <br /> ( ) Additional Unit Add-on ( ) I~tached <br /> <br />Dealers ..~,*n7 ~ ~ Year of ~ No. of Length Width <br />Name: ~.-0 ~' Manufacturer <br />Type( .~Wood°f Siding: 0.~Co mpType of Roofing: Square Footage: ~/,~O ~ No. of Bedrooms: 3 <br />( ) Metal ( ) Steel Pit Set: Energy: <br />( )Vinyl ( )Metal <br /> <br />mot si~:/C.,5' ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Account. <br /> <br /> ~ection: 3 P Township: ~:~.~ Range: ~ ~ Zone: ~ Map: ~ ~ <br /> <br /> Urban Growth Boundary? (~s ( ) No Water Supply: ( ) Privat~ Well ( ) Conununity Well (~i~y <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 stmcmr~ and will be my own general contractor. I understand that I <br /> <br />(~ I am an AUTHORIZED REPRESENTATIVE o f the propeny owner or the contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />A. Manufactured Placement/Connections $245,00 <br />0nclud~ EL, PL, ME connections) <br />State Surcharge $12.25 <br />Slate Fe~ $20.00 <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 />NAM~OFAPPLICANT(plcaseprin0: ,~}~ ~--~ O~ ~.~ PHONE: 7~ --~/¢~ <br />SIGNATURE OF APPLICANT: ~ DATE: ~a' ~ ~/7 ~ ~? <br /> <br />MC 15-Ol Rev3~5 <br /> <br /> <br />