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F()R OFFICE USE oNLYI <br />Received b.y: ~ I <br />DZaO:~g Va,,dat,om <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> <br /> 22O High Street NE <br /> Salem, OR 97301 <br /> 8:00 am-4:30pm ~hone 588-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMI'LETI:} ALL SECTIONS, THROUGI-I 4 <br /> Job Description <br /> <br />I FOR OFFICE USE ONLY <br /> <br />Reaidentiul(-X*~ New(~ Replaeean<t( ) Garage or Caq)on <br /> ( ) Attached <br />C~m~<iul( ) New( ) ~p~t( ) ( ) D~tached <br /> <br />2, Location oflnstallafion <br /> <br /> Si~ No. <br />Mo~le ~ome Pa~ S~ce 0 Y( ) N( ) <br />8¢¢tJo~ ~ O To~Mp ~ Range / ~ Z~e Map Water Su~ly: <br /> .................. Private Well ~ Spring <br />~Withh L~De~h Ac~s ~.~q ~eg.~t Comer Commu~Well( ) City <br /> <br />3. Contractor Information <br /> <br />Pr~y~ay Owner ] Maillng Address [Phone No. <br /> <br />( ) I ovm, reaide in, or wR1 maide in the completed structure. <br /> <br />( ) i will be my own general ¢o~ttaetor. <br /> <br />If I change my m~nd and do hire a general contractor, I will contract with a contractor who i~ registered with the Constmctlon Coniractofs Bo~ ed, and will <br />immediately notify Marion County of the name of tho ,ontraotor. <br /> <br />Contractor Buslnes* Name & g: I Mailing Address: I Phone: <br />( ) I am a registered burger OR [ha authorized repmseataave of a mgistereA builder. <br /> <br />Authorized agent or lea~ee: ............... [Mailing Address: I Phone: <br /> <br />4. Fee Schedule <br /> <br />A. (1) Manofac~ured Home <br /> <br /> or Modular Unit PlacemenffConnectlon <br /> <br /> (2) Sine Fee <br /> <br /> (3) State Surcharge <br /> <br /> (4) Zoning Surcharge (15.00 il- applicable) <br /> <br />B, (I) Mfg. d Smcture Storage Fee <br /> (2) Mfg.'d Structure S~orage l~newal <br /> <br /> O) Zoning Sumha~ge (15.00 if appljcab/e) <br /> <br />@ 20,00 = --~ or Reimpectlon <br />@ 9,10=__ <br />(ap 15.00 = -- D. Investlgatio~l Fee <br /> <br /> ~ 40,00 ~r hour (2 h~r mi~mum) <br /> $25.~=~ <br /> <br />@ $60.00 = <br /> <br /> (~ $40.00 =__ <br /> <br />TOTAL ~ $.__ <br />RECEIPT: <br /> <br />on the reverse side of this form. <br />Name of Applicant (please print): .Phooe; <br /> <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />