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FOR OFFICE USE ONLY1 <br />Received b.y:-- <br />Zoning V~,hdation: <br />Date: <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br /> COMPLETE ALL SECTIONS. 1 THROUGII 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> mo Sigh Street I FOR OFFICE USE 9NLY <br /> Salem, OR 97301 City S~!,,b. aek Requirenlents:,, <br /> 8:00 am-4:30pm Phone 588-5147 Pron!~ <br /> Cod*-A-Phm~ 588-7904 Left Side: R.~ght Side: <br /> FAX 588-7948 <br /> <br />I, ~ob Description <br /> <br />Resldential(~) New( ) Replac. e. ment(.~q Garage or'Carport <br /> ( ) Attached <br />Commemial( ) New( ) Replacem~t( ) ( ) Detached <br />'~allBfaeturmS s Year of '~7~ Color of ' LeOgth: Width: .... <br /> <br />Block Urban Gwwlh Boundaq'? <br /> <br /> r r {PfivateWe~ ( ) Spring ( ) <br /> <br />3, Conffactor Information <br /> <br />Property Owner [ Marling Artiness "[Phone No, <br /> <br />( ) I own, reside in} or will n~side ~n the completed s~ruemt~, <br /> <br />( ) I will I~ my own general contractor. <br /> <br /> hire subcontractors. I will hlre only sub¢ontractor~ registered with the Collstmction Contractors Board. <br /> <br />Jmmod~ately notify Marion County of t~ name of h% ~ntract~r, <br /> <br />I Makling Address: [ Phone: <br /> <br />( ) I am a registered builder OR the audlori~d representative of a i~egistered builder. <br />Authoriv~d agent orleasee: ]M gAddress: { Phone: <br /> <br />~a~,Fee Sphedule <br /> 1) Manufactured Home <br /> <br /> or Modular Unlt Ph ' 'oement/Conn¢~tlon ~ $182.00=__ <br />(2) State Fee @ 20.00 =__ <br />O) State Surcharge @ 9,10 ~ ~ <br /> @ 15.00 ~- -- <br />(4) Zoning Surcharge (1 fi.00 if applicable) m~-, <br /> TOTAL: $ -],.~x <br /> <br />B, (1) Mfg.'~ Structure Storago Fee <br /> @ $ 25.00 <br />(2) Mfg.'d Stmemr~ Storage Renewal @ 25.00 <br />O) Zotxing Sumhaqle (15.00 i~ applicable) @ 15.00 <br /> <br />C. Addidonallmpe-crion (¢ $60.00--__ <br /> or Re~spection <br /> <br />40.00 Fer hour (2 hour minimum) <br /> <br /> @ $40,00 <br /> <br />TOTAl,= <br />RE.C~IPT: <br /> <br />I hereby certify that the above infom~ation is correct and that I have read and understand the Infon~latlon Notice to Propezly Owners about Construction Responsibklities <br />on the reverse aide of this form. <br /> <br />Name of Applicant (pteasc print): Phone: <br />Signature of Applicant: Date; <br /> <br />Thi~ fee covers thc maBufaetured structure place, inent, plumbing connection, electrical connection and ttxechanieal connection. Site evaloatio~, ~cptie permit, electrical <br />service or plumbing water/rower lines ave separate required permits. MC 1 $.64 Kev 11-91 <br /> <br /> <br />