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FOR bFFIC,,~E USE ONLY[ <br />Received by- <br /> <br />Date: <br /> <br /> MARION COUNTY BUILDING I~SPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00 am-4:3Ogrn Phon~ $88-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> MANUFACTURED STRUCTURE PLACEMENT <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br />1. Job Description <br /> <br /> FOR OFFICE USE ONLY <br /> <br />L,k~ft side: I R. ight Side: <br /> <br />Residential( ~ New( ~ Raplaeeme~t( ) Garage or Carport ........ <br /> ( ) Almched <br />Commercial( ) New( ) Replaeera,mt( ) ( ) Detached <br /> <br />Serial #: Maaaracmm.,:,,. q '~ Approval Label: ~'~ 7 <br />TypeofSidlng: {-4~c:~ ........ Ty~e of Roofing: ~ <br /> <br />2. Location of Installation <br /> <br />Property Owner ~g~lJL. ~t~'T"/K,.tE~. <br /> <br />Subdivision <br /> <br />MobileHomePark ~ V I~ E C~ I~/~ E ~ E'e.~i~l..rlY&.~ <br /> Township ~,.K~ Range <br /> <br />Width <br /> <br />Lot Depth ~.~ <br /> <br />Z~e <br /> <br />Irreg. Lot <br /> <br />MaD <br /> <br />3. Contractor Information <br /> <br /> Urbaa Growth Boundacy? <br /> <br />IY() ~( '-).'~ <br /> Water Supply: <br /> l'riva~eWell ( ) Spine <br /> gommuaity Well { ~ City.,. <br /> <br />l'r°peayOwn~r~t~L t'O~/er',~a2~ [MalllngAddress~-l$'sa~t't 1~0 ~ ]Phon;No. <br />( ) I own, ~aide in, or MI1 reside ~ ~e ¢mplemd stmmu~. <br /> <br />( ~ undenmnd ~at I must ~smr as a constmcti~ c~or ff ~e stm~ is sold or offered for sale before or u~n comple~on, <br />( ) I wi~ be my o~ g~grM contm~or. <br /> <br />ff I hii~ stlbomtractors, I will hire only subcontractors registered with the Construction Contractors Board, <br />If I change my mhld and do him a general contractor, I will COntract with a contractor who is re~stemd with thc Consh'u¢llon Contractor's Boal'd, and will <br />immediately noilly Marlon County of the nam~ of th~ contractor, /~/o ~ ~ <br />ConwaetorguainessNam*&#:N~t~L~,~_ /~)o~Sit,. ~'at-l~5 [MailingAddress:/OO/7 ~',~' ~,:~4 I vhone: 777'--q7¢7 <br />( ) I am a registered bulldor OR the authodzad repmscnhative of a registered build¢4', /~g~Z~v~-dl <br /> <br />Authorized agent or 1¢as¢¢: [Mailing Address: [ Phone; <br />4. Fee Schedule <br /> <br />A, (I) Mamffactufed Home <br />or Modular Unit Placemeat/Connecaion @ $182,00 -~ <br />(2) State Fee @ 20,00 = ~.~/~ <br />(3) State Surcharge @ 9,10= <br />(4) Z~m,,g t!,~mvge (15.00 if appllcable) <br /> TOTAl,: <br /> <br />B, (1) Mfg.'d Structure Storage Fee <br /> @ $ 25.00 <br /> (2) 1Vffg,'d Structure Storage Ran~wal @ 25,00 <br /> (3) Zoning Surcharge (15,00 ff applicable) @ 15,00 <br /> <br />C. Additional ~specfion <br /> or Rdnspection <br /> <br />D. Investigation Fee <br /> <br />E. Other i~slx~ctions not listed <br /> @ 40.00 per hour (2 hour minimum) <br /> <br />$60,00 <br /> <br /> £q $4000= <br /> <br /> TOTAL= $."9 >,0%5 <br />RECEII=T: <br /> <br />I hereby certify that the above informallon is correct and that I have mad and understand the hi£ormation Notice Io ~roperty Owner~ about Construction Rcspon sJbililies <br />on the ~everse side of this form. <br /> <br /> MC' 15-64 Rev 11-9I <br /> <br /> <br />