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Fog OFFICE USE ONLY' <br />Received by: <br />Zoning Validation: <br />Date:. <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00 am.4:g0pm Phone 588-5147 <br /> Code. A.Phone 588-7904 <br /> FAX $88-7948 <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLETE ALL $1~CTIONS, 1 TI-IROUGH 4 <br /> <br />1. Job Description <br /> <br /> FOR OFFICE USE ONLY~I <br />{City Svmback Kequiremen,?:,,, <br /> <br />Residential{>< ) New(~) Replacement( ) ( ) Attached <br />Commercial( ) New( ) Replacemmt( ) ~) Detached <br /> <br />Manofactumf$ Year of Coinr of " Length: '' Width: <br />Sqrlal#:Z ~7 Manufacture: /j- 9/ Approvod Labe, l: ' ,, 5~.,~ <br /> <br />2. Location of Installation <br /> <br /> Y( )N( ) <br />8eaton ~ To~s~p ~ $ Ran,~ i ~ ~e Map WaterSu~ly: <br /> ........ Pfiva~WeH ( ) $pdng ( ) <br /> <br />3, Contractor Information <br />Property Owner ..... ] MailJllg Address {Phone No, <br /> <br />(~) I own, mdde in, or will ruside in the ¢omple~d structure, <br /> <br />If I hire subcontractors. I will hire only subcontractors registered with the Constmctlon Contractor~ Beard. <br /> <br />'If I change my mind and do hire a general contractor, I will contract with a emtraetor who ia mgiaterexl with th~ Construction Contractors Board, and will <br />immedht~ly notify Marion County of thc name of the contractor <br /> <br /> Business Name & #: ] Mailing Address: I Phone: <br /> Contractor <br /> <br />( ) I am a reglsteted builder OR the authorized r~presentatlvo of a regist¢l~d builder. <br /> <br />Authofiz~ed agent or leaxee: ]Mailing Address: I Phone: <br />4. Fee Schedule <br /> <br /> or Modular Unit Placanent/Conneclion @ $182.~ = <br /> <br />(2) Sram B¢¢ ~ : ~'~ = <br /> ~ :'9;10= <br />(3) State Surcha~e ~ 1~,~ =.~ <br />(4) ~tfing 8urcM~e (15,~ if applicable) <br /> <br />'DOTAL: $ <br /> <br />B. (1) Mfg,'d Structure Storage Fcc <br /> @ $ 25.00 ~,__ <br />¢2) Mfg,'d Structure Storage Renewal @ : 25,00 = <br /> (3) 7~alng Surcharge (15,00 if applicable) @ 15,00 = __ <br /> <br />C, Additional Inspection @ $60,00 = I <br /> or Reinspection <br /> <br />D, lavesqaaon Fe~ <br /> <br />Other inSl~Ctions not list~J <br />@ 40.00 per hour (2 hour mkdmuro) <br /> <br /> @ $40,00 =__ <br /> <br />TOTAL = $_ <br />RECEIPT: <br /> <br />NameofApptica, nt(please,dnt): ~C~c~ ~l~&'l' ~// ~one: ~&~- ~O~ <br />SignatumofA~pliaant: ~:~~~ Date; 7-- ~-*~ <br /> <br />semite or plumbing wa~r/sewer ~es are se~mte r~ui~d pe~its. MC 15-64 Rev l 1-91 <br /> <br /> <br />