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[~ceiyed By: Date i <br />Zoning By:. _CiW: I <br />Receipt#:_ Amount: $'4~ ~ '~ 1999 <br /> MARION COUNTY <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMD"NITY DEVELOPMENT CEIITER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem. Oregon 97305 <br /> 8:00 am - 4:30 pm <br /> 24 hr. Inspection Linc 373-4427 <br /> FAX 588-7948 <br /> <br />BUILDING INSPECTION <br /> <br />JOB DESCRIPTION <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br /> <br />Lel~: Right: <br />Special <br /> <br />MANUFACTURED DWELLING PERMIT APPLICATION <br /> *FLOOR PLAN REQUIRED* <br /> <br />RESIDENTIAL <br /> New Placement ~'~ Replacement ( Additional Unit Add-on <br /> <br />TypeofSiding: {'~Wood ( ~Me~l ( )Vin~l <br /> <br />Suer ~ Cen~ Home { / Yes t ) No (Provide ~¢umen~ation) <br /> <br />Garage or Carport <br />~ ) Attached ( ) Detached Height: <br /> <br />No. Of Sectiom: Length ~ Width; [~;~ Height: <br />TypeofRoofing: {~Comp ( )Steel t )Metal PitS~t:l )¥ ( )II <br /> <br />Number of Bedrooms: Existing: Proposed: ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Site Address: CiW: Zip: <br /> <br /> ( ) Mobile Home P~rk t I Mobile Home Subdivision <br /> <br /> Map: Zone: [ Parcel Size: ~, ~. ( ) SF ~'A AC <br /> Property Locator: { Pamel # J Wa~r Supply: ~ <br /> P~vat$ <br /> Well <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> UGB: () <br /> Y <br /> <br />( ) Community We{I <br /> <br />( ) City <br /> <br />() <br /> <br />() <br /> <br />I am thc PROPERTY OWNER and own, reside in, or will reside in the completed s~uetum and will be my own gee.~'al co~'actor. I und~ta~l that I must <br />register as a construction contractor if the structure is sold or offered for sale before or upon completion. Ill hire subcontractors, l will hi~e only subcontractom <br /> <br />Busin#ss Name (please print). <br /> <br />Mailing Address: <br /> <br />() <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br />Business Name (please print): <br /> <br />Mailing Address: <br /> <br />City: Zip: <br /> <br /> Phone: <br />Registration #: <br /> <br /> Street City: Zip: Phone: Fax: <br />4. FEES <br /> <br />A. (1) Manufactured Placement / Connections <br /> (includes EL, PL, ME connections & 30 feet <br /> each of sewer and water lines): <br /> (2) State Surcharge <br /> <br />$ 305.00 <br /> 15,25 <br /> <br />(3) State Administrative Fee 30,00 <br />(4) Zoning Surcharge, if applicable 30.00 <br /> <br />B. (1) *Earthquake-Resistant Bracing System (ER.B) $ 85.00 <br />(2) State Surcharge 4,25 <br />(3) State Adminis~ative Fee 30.00 <br /> <br />C. Miscellaneous Fees , <br /> (1) Additional Inspection or R¢inspection <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 /> TOTAL $ 3 ~0 'O <br /> <br /> * This fee is only charged when the ERB system is not <br /> part of the ori,ina, mannfactured dwelling installation, ltl.0.p.2~ l 0 b C{ ~ <br />1 hereby certify thai the above information is correct. Permits are non-t~ansferrhble and expire if work is not star~ed within 18'0 days of <br />issuance or if work is suspended for 180 days. <br />Name of Apphcant [Please Pnnq:' ' j.~ pg-C,9 ~ ~0~' t''''~. C~Z~,%~d.~__"t~- , . . <br /> MailingAddress:__ ~'~' t' .5 /...O[~t?'~ ~_.:l~tc- L,O Id la. ~1[, ~fi cad/q <br /> Phone:/'~ ~' th .'~ -' la 7 t~ -/~ O~ <br />Signature of Applicant: <br />MC 15-64 Rev 9/98 [~/ r t ~ -- <br /> <br /> <br />