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FOR CtTY I. SE ONLY <br /> <br />Zoning B~,: City: <br />Receipt #: Amount: $ __ <br /> <br />MARION COUNTY BUILDING INSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br /> 8:00 am - 4:30 pm <br /> 24 hr. Inspection Line 373-4427 <br /> FAX 588-7948 <br /> <br />FOR CITY USE ONLY <br />City Setbacks: <br />Front: Rear: <br />Left: Right: <br />Special: <br /> <br /> MANUFACTURED DWELLING PERMIT APPLICATION <br />1. JOB DESCRIPTION *FLOOR PLAN REQUIRED* <br /> <br /> RESIDENTIAL Garage or Carport <br /> l~}-Ncw Placement ( ) Replacement ( ) Additional Unit Add-on ( ) Attached ( ) Detached Height: <br /> <br /> NO. Of Sections: ~_~ Length: ~'~ Width: Z~'J/ Height: g~, ~' <br /> <br />De ale r ' s N amc: t~"/~.ne ~/~O.~t Year of Manufacturer: <br /> <br />Type of Siding: (,~ood ( ) Metal ( ) Vinyl <br /> <br /> TypeofRoofing: (d)'~omp ( )Steel ( )Metal PitSet:( )Y ~ <br /> <br />Super Good Cents Home Wes ( ) No (Provide Documentation) Number of Bedrooms: Existing: Proposed: .~ <br />2. LOCATION OF INSTALLATION <br /> <br /> City: ,~tt ~r/~ Z.~, '///~ Zip: <br />Site <br /> Address: <br /> <br />( ) Mobile Home Park ( ) Mobile Home Subdivision <br /> <br />] Cross Sheet: ,~,,~// L4'/.~¥.,,/~ ~ <br />Space g: Total ~ Spaces: <br /> <br />Map: Zone: ParcelSize: /.,ff.q ( ) SF <br />PropenyLocator Parcel#: <br /> <br />~ AC [ UGB: ()Y <br />I WaterSupply: {.~)~'Private Well ( ) Community Well ( )City <br /> <br />3. CONTRACTOR INFORMATION --- PLEASE INDICATE WHO 1S 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 thc structure is sold or offered for sale betbre or upon completion. Ill hire subcontractors, I will him only subcontractors <br /> registered with thc Construction Contractors Board If [ change my mind and do hire a general contractor who is registered with the Construction Contractors <br /> Board, l will immediately noti~ Marion County of thc name of the contractor. <br /> \ <br /> ( ) [ am the AUTHORIZED REPR~ESENTATIVE of the property owner or the contractor. <br /> Business Name (please print). <br /> <br /> Mailing Address: <br /> Street: City: Zip: Phone: <br /> <br /> I I 1 am a CONTRACTOR registered with the State of Oregon. <br /> Business Name (please print): <br /> Mailing Address: ..~-_/~o _~-~O.*d. <br /> Street <br /> <br /> / ~ - Registration #: ~ff-~ d~:9/.~ <br /> <br /> City: Zip: Phone: Fax: <br />4. FEES <br /> <br />A.(1) <br /> <br /> (2) <br /> <br /> (3) <br /> (4) <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 />State Administrative Fee <br />Zoning Surcharge, if applicable <br /> <br />$ 305.00 <br /> 15.25 <br /> <br />30.00 <br />30.00 <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 /> B. (1) *Earthquake-Resistant Bracing System (ERB) $ 85.00 NOTICE ?OTAL $ <br /> (2) State Surcharge 4,25 EFFECTIVE 7-1-99 <br /> (3) State Administrative Fee 30.00 <br /> * This fee is only charged when the ERB system is not STATE SURCHARGE CHANGE <br /> part of the original manufactured dwelling installation. FROM 5% TO 7% <br /> <br />I hereb5 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 of Applicant [Please Print]: ~'g'~s~'~ta~.,~$ · ~ <br /> <br />Signature of.Applicant: ~q",~.~ <br /> <br /> <br />