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FOR OFFICE USE ONLY/ <br />Rece. ived b.y:-- <br /> 1 <br />Zomng Vahdationt <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> FOR OFFICE USE ONLY <br /> 220 High Street NE <br /> Salem, OR 97301 l Si[Y Setback Requirements; I <br /> 8:00 am.n:30pm Phone 588-5147 I P~om: Rear: / <br /> Code-A-Phone 588-7904 I Lc~t Side: Right Side: <br /> FAX 588-7948 <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLBTI~ AIA. SECTIONS. 1 THROUGII 4 <br /> <br />1. Job Description <br /> <br />Residential( ) New( ) Replacemmt( ) Garage or Carport <br /> ( ) Attached <br />Commcmial(X) Ncw~) ......... Replacement( ) ( )Detached <br /> <br />2. Location of Installa~on <br /> <br />Mo~eHomePa~ S~¢e~ Y( )N( ) <br />Se¢im ~s~p Range tree Mep Water Su~ly: <br />.............. PfivamWell ~ Spring <br />L~ W~d~ ~Ot ~t ~h ~ ~ I Aom* I~eg, ~t Comer ~mm~ty W~( ) ~ <br /> <br />3. Contractor Information <br />Property Owner ~O. kliC[ ('O('l]~(~u.~410,~.[4'~ alllngAddre:: Ii3VZ~3! D-%~ fid, I?h°neN°l ~ <br />'(~ l o~, reside in, or ~11 reside ~ the c~ptemd ~mum. <br />( ) I undc~mnd ~at I must mgismr a~ a con*tmc~ c~tmcmr if ~e stratum is sold or offered for zale before or u~n cmplcfion, <br /> <br />( ) I wiB ~ my o~ g~eral oontra~o[ <br /> <br /> hke subcontractors. I ~Lt him only subcontractors registered w~th the Construction Contractor~ Board. <br /> <br /> I change my ming and do hire a general contractor. ! ~11 contract with a contractor who is registered with the Construction Contractor s Board. a ~d will <br />~mmed~ately notify Marion Cottager the name of the eonaaetor. · <br /> <br />k) I am a registered builder OR thc authorized repr6sentativ¢ of a r*gistetcd build ex, <br /> <br />4, Fee Schedule <br /> <br />A, (1) Manufactured Home <br /> or Modalar Unit Pla¢cmenffConnection @ $182,00=__ <br /> <br /> (2) State Fee <br /> @ 9,10--__ <br /> (3) State Surcha~g~ @ 15.00 = <br /> (4) 7~ning Surcharge (I5,00 ifapplioable) <br /> <br />TOTAL: $___ <br /> <br />B, (1) Mfg,'d Structure Storage Fee <br />(2) Mfg/d Structure Storage Renewal @ 25.00 <br />(3) Zoning Surcharge (15 00 ir applicable) @ IS100 <br /> <br />C. Additional Inspecton <br /> or Re&aspaet{0n <br /> <br />Di Investigation Fee: <br /> <br />E, Other Jnspaet~oo$ not listed <br /> @ 40.00 per flour (2 hour minimum) <br /> <br />$60,00 =___ <br /> <br /> q~ $40,00 = <br /> <br />TOTAL= $ <br />RECEII~I',, <br /> <br />I hereby 'certify that the above information is correct ~nd that I have read and undcr~tand the Information Notice to Property Owners abotlt Co~$troctio~ Respon fibil/ties <br />on the reverse side of this feral /~ ~ <br />Nameof Applicant (please prin~I ~ 1~ ~T l'~ ~1 ~ ~ ~l Phone;.~ %~ tf'~[{~ I g ~- l~ ~ q q <br />Siguature or Applicant: t~ /'~LLi/~Z/~.~ Date: '~' ' ' <br /> <br />service or plumbing watcdscwer lines are separate required permits. <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />