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Ii~F~)R CITY VALIDATION <br />ecdi~ed By: <br />oning Validation: <br />ate: <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> 1. JOB DESCRIPTION <br /> ~ New Placement <br /> ( ) Replacement <br /> ( ) Additional Unit Add-on <br /> <br />Dealers <br />Name: <br /> <br />Type of Sidlng: <br />~ Wood <br /> ) Metal <br /> ) Vinyl <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 /> JUL <br /> <br /> FOR CITY USE ONLY '-] <br />2ity Setback Requirements: <br /> <br />Ri~ht Side: <br /> <br />Year of <br /> <br />Type of Roofing: <br />~ Comp <br />( ) Steel <br />( ) Metal <br /> <br />Garage or Carport <br />( ) Attached ~./~,/~ <br />( )Detached <br /> <br />fltUttON-COUNTY- <br />BUILDING INSPECTION <br /> <br />No. of Length [ Wide2~ <br />Sections ~ ,~7/~ OD~ <br />Square Footage: ~ ~ <br /> ~ No. of Bedrooms: <br /> <br />Pit Set: <br /> <br />2. LOCATION OF INSTALLATION <br />Mobile Home Park Name' ace #' <br /> <br /> Urban Growth Boundary? (~) Yes ( ) No Water Supply: ( ) Private Well ( ) Community Well ~) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> [ 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 [ <br /> must register as a construction con.actor if the s~mcture is sold or offered for sale before or upon completion. If I hire subcontxactors. I will hixe onl <br /> subcontractors registered with the Construction Contractors Board. It' I change my mind and do hire a general contractor who is registered with th <br /> Construction Contractors Board. I will immediately notify Marion County of the name of the contractor. <br /> <br /> ( ) I am a CONTILACTOR regislered with the Stat~ of Oregon. <br /> Business Name: Registration No.: <br /> <br /> Mailing Address: Phone: ~ <br /> ( ) I am an AUTHORIZED REPRESENTATIVE of the pyoperty owner or the contractor. <br /> <br />Name: <br />~g Address: Phone: <br />4. FEE SCHEDULE <br /> <br />(includes EL, PL, ME connections) <br />Stale Sureharge <br />State Fee <br />Zoning Surcharge (if applicable) <br /> ~ TOTAL <br /> <br />$245.00= ~5:~5/5'7.'~'- B. Additionaltaspectioni <br /> (beyond third inspection) <br />$12.25 = ~ EeinspectionFee <br /> <br />$20.00 = ~0. <br /> <br />$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 />NAME OF APPLICANT (please print): ~ <br /> <br />SIGNATURE OF APPLICANT: <br /> <br />MC 15-64 Rev3/95 <br /> <br />__DATE:~ <br /> <br /> <br />