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~ .... .a- .............................. MARION COUNTY BUII~ INSPECTION i .............................................. ~ .................. <br />I FO.R, CITY USF~I~ . COMM~ITY DEVE~N~R~ ] FOR CI~ USE ON~Y <br />~ Re~e~By~-- D~t~:.~ 3150L~cas~r~~b~ City Setbacks: <br />~ Zen g Y: ~ ~' ~ S~em, Ore~ ~'F~ nv ~9 Re~' <br /> ~aeipt g: Amount: $ ..... ~2- -- ~ ~2~:~ <br />[ o.uu ~ - ~:3~m ' ' ~ /~ ~ ~ Right: <br />...................................... 24 hr. Inspection Line 37~ d~d~: ' <br /> <br /> 1. JO~ DESCRI~ION I~p~r 'FLOOR <br /> RE~D* <br /> PL~ <br /> <br /> ( ~ew Pl~e~nt ( ) Replac~men~ ( ) Additional Unit Add~n ( ) A~ched ( ) ~taehed H~ight: ' <br /> <br />TyI~ of Siding: (~ood <br /> <br />( ) Metal ( ) Vinyl <br /> <br />NO. <br /> Of Sections: <br /> <br />,Typeofgoofing: (~omp ( )Steel ( )Metal PitSet:( )Y ( )N <br /> <br />Super Good Cents Home ( ~es ( ) No (Provide Documentation) Number of Bedrooms: Existing: Proposed: <br />2. LOCATION OF4 S A <br /> <br /> tZipPhone <br /> ~Mobilc a~e P'k () Mobile Home Subdivisio~- , ~ [ Sp~ ~: . : I~ ~ ~S: j ~ <br /> <br /> ~pe~ Locater: ~ P~I~: ~ Water Supply: ( ) Private Well ( ) Communi~Well <br /> <br />3. CONT~CTOR INFECTION -- PLEASE INDICATE WHO IS DOING ~E WORK <br /> <br /> Bo~d, I will immedlataly noti~ M~ion Coun~ of~e n~e otthe cont~tor. <br /> <br />( ) I am the AUTHOR[ZED REPRESENTATIVE of the property owner or the contractor. <br /> Business Name (please print) <br /> <br /> Mailing Address: <br /> Street: City: Zip: <br /> <br /> I am a CONTRACTOR registered with the State of Oregon. <br /> Business Name (please print): <br /> <br /> Mailing Address: <br /> <br />() <br /> <br />Registration #: <br /> <br /> Str~¢t City: Zip: Phone: Fax: <br />4. FEES <br /> <br />A. (1) Manufactured Placement / Com~ections <br /> (includes EL, PL, ME connections & 30 feet <br /> each of sewer and water lines): $305,00- <br /> (2) State Surcharge 15,25 - <br /> <br />(3) State Administrative Fee 30,00 .. <br />(4) Z ~-g~; i f-a~lieabTe ........ Z ...... 30.00'. <br /> <br />B. (1) *Eatnhquake-Resistant Bracing System (ERB) $ 85.00 <br />(2) State Sumharge 4.25 <br />(3) State Administrative Fee 30.00 <br /> * This fee is only charged when the ERB system is not <br /> part of the original manufactured dwelling installation. <br /> <br />C. Miscellaneous Fees <br />: (1) Additional Inspection or Reinspection <br /> @ $60/per inspection <br /> [Assessed for inspections beyond the third <br /> Inspection] <br /> (2) Investigation Fee ~ $305.00 <br /> (4) Other Inspections @ $50 per inspection <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 <br />issuance or if work is suspended for 180 days. <br />NameofApplicant[PlcasePrint]: '~I~I,.I/~A, "~,-.~ --.. <br /> Mailin&Address: ~' O' (~ ~'~-~ ~'M~,t.~ ~ C2/-[~-~Ot. ff <br />Signature of Applicant: ~ \ ~ .... Date: <br />MC 15-64 Rev 9/9g I~'~.~,m... ~ <br /> <br /> <br />