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FOR OFFICE USE ONLY <br />Received By; ~Z~ ~ ~.~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 High Street NE <br /> SaIem, OR 97301 <br /> <br />8;00 a,m.-4:80 p,m, Phone $88-5147 <br />Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />City Setback Requirements'. <br /> <br />Left Side: /~'~ Right Side: ,r<~-/ <br /> <br />MANUFACTURED STRUCTURE & SEPTIC PERMIT APPLICATION <br /> <br />[L~ Single Family Dwelling [ ] Office [ ] Classroom [ ] Storage <br />[[L~RES [ ]COM [~ew [ ]Storage [ ]Occ. Chg. [ ] Replacement [ ]TechnicalRev~w <br /> <br />COMPIL~ ~ e AIL SECTIONS, 'l THROUGH 4 <br /> Location of Installation <br /> <br /> Dx Block <br />Park ...... S~at~ ~ .......... <br />% To~sMp <br /> <br />2. Installation 4. Fee Schedule <br /> <br />Exi~8ng Site Eval~on [] Existin <br />Proposed Installation P~rmlt [] <br />Existing S~pdc System [] <br /> <br />~isfing Dra/zLr~,Id Lmgth; <br /> <br />l~0mper Form Air. hcA [] <br /> <br />BUILDING tNSPEO'flO,~ <br /> <br /> / <br /> ~I' I have mad this application in it~ enti~ty and certify that the ~latcd information is Line and <br /> <br /> ~ performing ~>rk on a property I Own or oompy. <br /> '.~YJ.,am a mgbtered builder OR [ ] the authofi:~t mpm~eam6w of a rcgltmred b~ild~r <br /> '~" The work w/Il be performed by a mglcmfed build.r, <br /> <br /> agree to build acco tdinljt~o the suhen~ted plans and ~fJecii-tcalion s, thc ~.ws oft~ <br />Signatu?, of Applicant ~~ <br /> <br /> Iletn x Cost = Total <br />A. Each Mfg.'d }lame Or Modtdar Unit <br /> <br /> Each Mfg,'d IInme or Modular Unit <br /> StateF~ / ~,~ <br /> WatedSewer Cmn~tim Fee <br /> ~ectric~ Sewi~ <br /> El~[ric~ Conncctim 35.~ <br /> (l) 'l~tal of Abow Fees <br /> (2) 5% Sram Surcha~ (,05 x Al) <br /> (3) ~mg Surcha~c (.05 x <br /> Subtetal <br /> <br /> B, Mfg,'d Structure Storage Fee 25.(XI <br /> <br />1). Now Septic In~tallatioll P<~n~il Fee <br /> <br />F. Repair Permit Fcc <br />G, On-Site Technical Ruview Fee <br />II, Investigation Fee (il required) <br /> <br /> @ $40.00 per bout (2 hour min.) 40.(g) <br />K. City Fee <br /> <br />TOTAL AMOUNT DUE <br /> <br /> <br />