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[FOR OFFICE USFXON~Y <br /> /g eeived by: :,., 7 ta ? I <br />· /Zoning Validation~//~ ~ <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8;00 am.4:30pm Phone 588-514'7 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLgTE ALL SECTIONS. 1 THROtJGH 4 <br /> <br />1, Job Description <br /> <br />FOR OFFICE USE ONLYI <br />City Setback Requirements: <br /> <br />........ - .......... r ---,-, Garage or Carport <br />Resid~Ilt|al(~) NeW~) Replacement( ) ( )At~ched <br />Comme~ial( ) New( ) Replacemmt( ) ( ) Detached <br /> ....... <br />~ App~ed ~: <br /> Man~a~me* Year of { Color of Wrd~h: <br /> <br />2. Locafionoflns~lhfion <br /> <br /> ......... Private We~ ( ) <br />LotWidm ~%5'~ LaDe~ D~{ Acres ..........~g.~ Comer .... Co~umtzW~( ) City <br /> <br /> Contractor Information <br /> <br />~) I o~. reside ~, or ~ mdde ~ ~ c0m~e~ s~aum, <br /> ) I un~d ~at I must ~s~r as a c~stm~ c~t~ctor ff ~e s~ is sold or ~emd for sale befo~ or u~ c~plefion. <br /> <br />If I him subcontractors, I will him only subcont fa*tots rcgistercd with the Conatmaion Con,raetor~ Board, <br /> <br />If I change my mind and do him a general ~ontraotor, I w~ll contract with a ccotcaclDr who is registered with the Construction Contractor s Bol rd, and will <br />immediately notify Marion County of the name of the contractor. <br /> <br />(X) I am a registered builder OR lhe alJIllorlz~d representative of a registered bu/lder. <br /> H <br /> <br />Authorized agem or leasee: tr~ - . } ~ Mailing Address <br /> .fa, .. [ ezf <br /> <br /> I <br />4:; Fee Schedule: <br /> <br /> orMo~arUnltPhcem~C~ne~ion ~ $18~-~= /ff~ C, Addifionalhsp~fi~ <br /> (2) S~F~ ~ 2°.~~ ora~v~on <br /> (4)(3) ~ng Sufc~e (15.~ ff applicable)State Surcha~e ~ I5.~ ;~ D. ~vCsOgafion Fee <br /> ~ 40.~ ~r hour (2 <br /> <br />(1) Mfg,*d Struetux~ Storage Fee <br /> @ <br />(2) 1Vffg.'d Sgruetul~ Storage Renewal @ ~5,00 = <br />{3) Zoning Surcharge (15.00 ff applicable) @ 15.00--.__ <br /> <br />I hereby cenily that thc above infomlalion is correct and that I have read and understand the Information Notice to Property Owners aborn Conltmetdo~ <br />on th¢ r~vers¢ side Of this form. ~ <br /> <br />This fe~ ~overs the manufactured structure ~lacernent. plumbing connection. ~e~t~ieal cort0eetio~ and mechanical connection. Site evaluation, septic permit, electrical <br />service or plumbing water/sewer lines ate separate required p~rmitz. MC 15-64 Rev 11-91 <br /> <br /> <br />