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tr~ ................................... ~_ MARIO~ COUNTY BUILDING INSPECTION <br /> FOR CITY US~.(IN, LY ~ ,n .... ~la.~t?"a~/"~'~ITY DEVELOPMENT CEN~R <br /> ~?ed By:_~ Date: ~~/~ ~ ~ ]~1~. NE - Suite C <br />Zoning By: ~ Ci~:~l)~ ~al~ln 97305 <br />L Rccaipt ~: Amouta:$~__~'- ~ ~ ~:~10 pm <br /> .................................... . ~ ~ 2~r:~pgcti~c 373-4427 <br /> - ~ ~:C~A~8.7948 <br /> <br />1. JOB DESCRIPTION <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br /> <br />Left: ~; Right: <br />Special: ~ ,nd O ~ <br /> <br />RESIDENTIAL <br /> New Placement ( ) Replacement <br /> <br />( ) Additional Unit Add-on <br /> <br />Dealer's Nam~~f2?~ Year o f Manufacturer: ~ <br />TypeofSiding: ~Wood ( )Metal ( )Vinyl <br /> <br />Super Good Cents Home ~ Yes ( ) No (Provide Documentation) <br /> <br />Garage or Carpor~ <br />(~Attached ( ) Detached Height: <br /> <br />No. Of Sections: ~ Length: ~"c~ Width: 2 g Height:/.~~ <br />TypeofRoofing: ]~N0Comp ( )Steel ( )Metal ~Se~.'( )Y ( )N <br />Number of Bedrooms:a Existing: Proposed: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> ()MobileH~mePark ._. ( ) Mobile Home Subdivision ~- [ Space#: ~- Total#Spaces: .~- <br /> <br /> Map:/0 5CO~.~.~ Zone: ~'~O ParcelSize: ~--~qt~D (~}.SF ( ) AC [ UGB: ~Y () N <br /> gtopertyLocmor: Parce #: } WmerSupply: ( ) priv~eWell ( ) Community Well ~Cily <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <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 must <br />register as a construction contractor if the structure is sold or offered for sale before or upon completion. If! hire subcontractors, I will hire only subcontractors <br />registered with the Construction Contractors Board. Itl change my mind and do hire a general contractor who is registered with the Construction Contractors <br />Bo~d, I will ~mmediatety notify Marion Count~ of the name of the e~ontmctor. <br /> <br />() <br /> <br />[ am the AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Business Name (please print) <br /> <br />Mailing Address: <br /> Street: City: Zip: Phone: <br /> <br />() <br /> <br />I am a CONTRACTOR registered with the State of Oregon. <br />Business Name (please print): <br /> <br />Registration <br /> <br />Mailing Address: <br /> <br />4. FEES <br /> <br />Street City: Zip: Phone: Fax: <br /> <br />A. (1) Manufactured Plagemen~t / 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) Z e.".Lng <br /> <br />B. (1) *Earthquake-Resistant Bracing System (ER.B) $ 85.00 <br />(2) State Surcharge 4.25 <br />(3) State Administrative Fee 30.00 <br /> <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 ~ $50 per inspection <br /> <br />TOTAL <br /> <br />$ <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 /> <br /> MailingAddress~- q-tI~ I,G~ie ~. X7~~' ~..~al,atn, x <br /> t-,Phone: _, ~'0 :~ '" a4/~ ~ ~-~'l I <br /> MC 15-64 Rev 9/98 - 0" ' '~'"~"~'~_~ ' <br /> <br /> <br />