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"F°I OFFICE USE ONLYl <br />' Received by:~ I <br />Zoning Validation: <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00 am-4:g0pm Phone 588-5147 <br /> Cod,.A.Phone 588-7904 <br /> FAX ~$8-7948 <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> <br />COMPLSTE ALL SECTIONS, 1 THROUGH 4 PERMIT APPLICATION <br />1. Job Description <br /> <br />Front; <br />L~t Side: Pdght Side: <br /> <br />FOR OFFICE USE ONLY <br /> <br />R~sideatial New Replacement( ) Garage or Ca,pot; <br /> ( ) Attuned <br />Comme~al( ) New( ) ~plac~t( ) ( ) Dct~hed <br />Manufammfs Year of ~lor ~, L~g~ Wide: /~ 0 <br />8~dal,: Manufa~: ~e~ App~ved~l: ~ <br /> <br />2. Location of J <br /> <br />Subdivision ~ ......... <br />........ L~ ............. [BI~ Urban Growth gounda~? <br />Mo~,.~e~at $~ce~ Y( ) N( ) <br />Scion , , ~ To~s~p : Range ~e Map Wamr Su~ly: <br />~t Wid~ ~t De~ Ac~s ..... I~g. ~t Comer Pfiva~ Well ( ) Sp~g ( ) <br /> ..... ~mmu~ty WeE ( ~ Gty,, ,,,,{ ) <br /> <br />3. Contractor Information <br />Poapezty Owner ] 'Mailing Addl~sS "' ]~hone NO. <br />( ) I o~, ma~e in, or ~ ~side ~ ~ completed stratum.' <br /> <br />( ) I wiE ~ my o~ gm6rM eontra~or. <br /> <br /> If I him subcontractors. I will him Only subcomractors mgisterM with the Con shmclion Contractors Board. <br /> <br /> If I change my mind and go hi~ a general eotltraetor~ I will contact with a ¢catractor who is reglst~md with the Construction Contractors Board, and will <br /> knmediat~ly notify Marion County o~ namo o~the contractor.. ~ , <br /> Contractor Bas/ne,a Name & #. ilin Add~ess <br /> ( ) I am a registered builder OR the authorized ~pmsr. ntative of a ~gistemd builder. <br /> <br /> Authorized agea~ or l~asee: lMm, Address: I Phone: <br /> 4. Fee Schedule <br /> <br /> or Modular Unit Placemmt/Cmnecrioa / @ $182,00 = .~ C. Additlmal Inspection @ $60.00 <br /> (2) St,tePee / ~_ 20.0o=.~t_ oram~p~eaon <br /> <br /> ~ I @ , = / D. Investigation Fee <br /> <br /> ~..~AL: $~-~-~./~ E, Other inapect~ons not listed <br /> B, (1) Mfg,'d Structure $~orage Fee @ 40,00 per hour (2 hour minimum) <br /> @ $ 25,00 ~__ <br /> (2) Mfg/d SImctum Storage l~e~wal @ 25.(10 = <br /> (3) Zoning Surcharge (1 $,00 ff applicable) @ 15.00-- <br /> <br />Name of Applicant (please print): ,Phone: <br />Signature of Applicant; Date: <br /> <br /> MC I5-64 Rev 11,91 <br /> <br /> <br />