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IFOR ~FFICE USE ONLY] <br /> ~ecelved byl-- <br /> Zoning Validation: <br /> Da~e: <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br /> COMPLETE ALL SI~CTIONS, 1 THROUGH 4 <br /> <br /> 220 Ffigh Street NE <br /> Salem, OR 97301 <br />8:00 arnM:30pm Phon~ 588-5147 <br />Code-A-Phone 588-7904 <br /> FAX 5880948 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> FOR OFFICE US~E _ONLY <br /> <br />Residential(~ New( ~ l~placeme~t( ) ( <br /> <br />Manufacm~fs Year of Color of ~ .... Wide: <br />Serial 0: Manufacture; App~ed <br /> <br />Secti< ~3 Town,hp 3 5 Range ~ ~ ~e Map WaterSu~ly: <br /> PrlvamWeU ( ) Spring <br />Lmwid~, .... ~.,~ ....... ~De~ ilo Acres ~g,~t Comer CommuaityWO~ City <br /> <br />( ) I o~, ~SMe Jrt, or will reside in ~emplemd stratum. <br /> <br />( ) I wiU be my own g~erM <br /> <br />ff [ hire subcontractors, I will hire only subcontraaors ~zgisiered with the Construction Coutraetors Boa~, <br /> <br />If I change my mind and do hire a general Contractor, I ,Mll contract with a ¢~mtmctor who is registered with the Constra¢fion Contractor s Board, and will <br />immediately notity Marion County of the name of thy contraJaor. <br /> <br />(~o..~i~am areglslerodbuilderORtheauthodzod mpmsentafiveofaregistemdbuildex, A/, ~: ~//o'-° ~ /o~. )Or~ <br />Autho~:'~d agent or lessee: [Mailing Addgsg: ] Phone: <br /> <br />Fee Schedule <br /> <br />A. (1) Manufactured Home <br />or Modular Uoit Plaeemtmt/Connec~ion @ $ I82,00 -- __ <br />(2) State Fee @ 20.00 ~__ <br /> ~ ' @',': 9~I0~-~__ <br /> ~3) State Sumharge @ 15.00 =__ <br /> (4) 7~ning Surcharge (l 5,00 if applicable) <br /> <br />TOTAL: $___ <br /> <br />B, (1) Mfg,'d Structure S~orage Fee <br /> @ $ 25.00--__ <br />(~) Mfg,'d Structure Storage Renewal @ 25.00 n __ <br />(3) Zoning Surcharge (15.00 if applicable) @ 15.00 = -- <br /> <br />C. Additional inspection (l'} $60 X = <br /> or Relmpeetlbn <br /> <br />D- investiga~oa Fee <br /> <br />E. Other inspections not listed <br /> @ 40.00 per hour (2 hour minimum) <br /> <br /> @ $40.00 = <br /> <br />TOTAL= $___ <br />I~CEII~I'; <br /> <br />on Ihe reverse side of this form. · ~ <br /> <br />NameofA[Jplieant(pleasepNnt): O Phone: ~57- 8 3~ g <br />Signatu~ofApplieant: X ~.~ ~' ~' Date: ,5-16 -- ~ ,, <br />semite or plumbing wamr/sewer lines am ~e~mte r~ui~d ~its. MC 15-64 Rev 11-91 <br /> <br /> <br />