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[FOR OFFICE USE ONLY1 <br />{ Received by:~ <br />~ Zoning Validation: <br />[ Date: <br /> <br /> 220 High Street NE <br /> Salem, OR 97~1"~- <br />8:00 amd:30pm 1~1 <br /> Code-A-Phone 588-791Ya. <br /> FAX 58.8-7948 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> FOR OFFICE US~E _ONLY[ <br /> Setback Reqmrement~: <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />CONIPLETE ALL SEC'lIONS, 1 THROUGII 4 <br /> <br /> Job Description <br /> <br />..... R,sidemtial( ~)'" New( ) Replacement(~) Oatage or Ca¢olX <br /> ( ) ArraYed <br />Commercial( ) New( ) Replacement( ) ~) Detached <br />~anufac~u~Fs DIlL m Y~arof Co]orof ' Length: / Width: <br /> <br />2. Locatioe of Installation Q~% '5 '7o$ ~ .... <br /> <br /> ~co~ ,, OR q qoog <br /> Subdivision %~ C~< ~5~V~ L~ q }Bl~k I ~ Urban Growth Boundaw? <br /> Mobile Home Pa~ S~ee~ Y( )N( ) <br />Scion To~shp ~nge Zme Map Water Su~ly: <br /> Pfiva~WeH ( ) Sp~g ( ) <br />Lot Wid~ ~ / / Acres ~g. ~t Comer <br />..... ~ Lotm~ [qg CommuMtyWcH~ ~j.ty { ) <br /> <br />3, Contractor Information <br /> <br />if I him subcolltractors, ~ will him only subcontractors registered with the Constmctlon Contractors Board, <br /> <br />If 1' ehaoge my mind and do him a general contractor, I will contract with a cmtractor who is registered with the Constmotion Contractor's Board, and will <br />immediately notify Marion County of the name of the contractor. <br /> <br />( ) I am a registered builder OR the authorized repmsentalive of a registered builder, <br /> <br />Fee Schedule <br /> <br />A. (I) Manufactured Home <br />ct Modular Unk Placemeat/Connection @ $18%00 = <br /> (2) Stale Fee @ 20.00 = -- <br /> @ 9,10= <br /> (3) State Surcharge @ 15.00=__ <br /> (4) Zoning Sucel wge (15,00 'fapplicable) <br /> <br />TOTAL: $ <br /> <br />C. Additional Inspe¢lion {_~ $60,00 <br /> or Rethspectlon <br /> <br />D, Invcs0gation Fee <br /> <br />E. Other inspectiOtlS not listed <br /> @ 40.00 per hour (2 hotlr minimum) <br /> <br />B, (l) Mfg.'d Structure StOrage Fee <br /> @ $ 25,00 =__ <br />(2) Mfg.'d Str~x¢tu~ Storage Renewal @ 25.00 ~ -- <br />(3) 7x*~ing Surcharge (15.00 if applicable) @ 15.00 = <br /> <br /> (~ $40.00=__ <br /> <br />'I'O'I~L= $ <br />RECEIPT: <br /> <br />I hereby ¢oaify that the abow information is cornet and that I have ~ad and under~tand the InfOrmation Nolice to Prope~y Ownet$ about Ccm~ouctlon <br /> <br /> <br />