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Received By: ~ Date' <br />Z~ing By: ]~c.~ Cit~: ~f'O(q <br />Re~ipt ~:~ AmountS <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL <br /> ~Ncw Placement ( )Replacement <br />Dealer'sName: ~-~t'5o,~.~ ~/~d <br />Type of Siding: (.~Wood ( ) Metal <br /> <br /> MARION COUNTY BUILDING 1NSPECTION,~ ~ ................................................................... <br /> COMMUNITY DEV~'~I~_T, gE,N.T,~/ [ FOR CITY USE ONLY <br /> 3150 Lancaster ~fi[J.~q~J2~ [~(//J .... [ ~JW Setbacks: <br /> <br /> 24 hr. Inspection U~37~7 ~ ~/~al: <br /> FAX 588-794~ d /.~,Q.~ ~ .......................................................... <br />MANUFACTU~D DWELLING P~~TION <br /> tnSPECTiON *FLOOR PLAN REQU~D* <br /> <br /> ( ) Additional Unit Add-on ( ) Attach~ ( ) Dc~d Height: <br /> <br /> ( )Vinyl Ty~ofRooflng: ~Comp ( )Steel ( )Metal PitSet:( )Y ~)N <br /> <br />Super Good Cents Home (~ Yes ( ) No {Provide Documentation) <br /> <br />Number of Bedrooms: Existing: Propoaed: .~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />() Mobile Home P~k <br />Map: Zone: [ P~cel Size: ~O~ ~ (~) SF <br /> <br />Zip~ 724 Phone: <br />Total#Spaces: <br /> <br />( ) Ac {UOB: ~y () N <br /> Water Supply: ( ) Private Well ( ) Community Well {fi{ City <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />O <br /> <br />1 am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general ¢:ontrac'mr. I understand that I must <br />register as a constmation contractor if the structure is sold or offered for sake before or upon completion. Ill hire subcontractors, I will hire only subcontractors <br />registered with the Construction Contractors Board. If I change my mind and do hire a general contractor who is registered with the Construction Contractors <br />Board, I will immediately notify Marion County of the name of the contraator. <br /> <br />() <br /> <br />I am the AUTHORIZED REPRESENTATIVE of the property owner or the contractor. <br />Business Name (please print) <br /> <br />Mailing Address: <br /> <br />Street: City: Zip: Phone: <br /> <br />I amaCONTRACTORr~gistexedwi.th_the Stale ofOregor/~ e~ ~ <br />Business Name (please print): ~',. kO~4) ~ ¥~ x{-..~L~ ~ \ ~ * Registratiat? #: <br /> ailthgAddres,: fPO ×qtO - <br /> Street Ci~: Zip: Phone: F~: <br /> <br />4. FEES <br /> <br />A. (1) <br /> <br />(2) <br /> <br />Manufactured Placement / Connections <br /> (includes EL, PL, ME connections & 30 feet <br /> each of sewer and water lines): <br />State Surcharge <br /> <br />(3) State Administrative Fee <br />(4) Zoning Surcharge, if applicable <br /> <br />$ 305.00 <br /> 30.00 <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 /> * 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 Reinspectioa <br /> ~ $60/per inspection $ <br /> [Assessed for inspections beyond the third <br /> Inspection] <br /> (2) InYestigafion 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 /> <br />Name o f Applicant ]Please Print]: ~.~v%. /~l~. <br /> MailingAddress:__['~t')~ [,~e' r-~_~-~ ' <br /> Phone: .~O '~ ~l~'g-~'_. '-~ <br />Signature of Applicant: ~lt~'o~a ~ ~t. ~ Date: <br />MC 15-64 Rev 9/98 X <br /> <br /> <br />