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MARION COUNTY BUILDING INSPECTION <br /> 220 High SUF~J.~XW-.w ]FOR,OFFICE USE ONLYI <br /> Salem; OR <br /> <br /> MANUFACTURED STRUCTUR_E~i~I~F~ ~ ~ <br /> PERMIT APPLICATION ' <br />COIV[PLgTE ALL SECTIONS, 1 THROUGH 4 <br />1. Job DescrJ ~on .~ MARION (~OUNI'Y <br /> <br />2. Location of Installation <br /> <br />Property Ow.~' ~ ~ ~ : [ M~$ Add~s~ <br /> <br /> ' , .,, CommumLy Weg ( ) ~$ty <br /> <br /> 3. Contractor Information <br /> l ropertyOw~*r~Td~L/ ~J'~qD/~lt~.~ ]M~gAdd~s~ ~ <br /> <br /> ( ) I un~d ~at I mu$t ~$s~r as a ¢~stmefi~ eont~c~ ff ~e a~m ~ soM or ~o~d for sale bzfo~ or U~ ¢~pleton, <br /> <br />H I eh~ge my m~d ahd do him a gene~ ~e~r~ I wffi ~et Wiffia ~ae~ Who is ~,~md wi~ ~e Cons~eflon contract.s Boa~, and will <br />~h~y no~y Mafi~ Co~ty of tho n~¢ ~ ~e ~ontr~r. ~ ~ <br /> <br />4. Fee Schedule <br /> <br />A, (I) Manufa~mured Home <br /> <br /> or Modular Unit PlacemmtYCo~nection <br /> (2) State Fee <br /> <br /> (3) State Surcharge <br /> (4)~ <br />B, (l) Mfg.'d Sttuetu~ Storag~ <br /> (g) M£g;'d Stmcmr~ Storage Renewal <br /> <br /> (3) Zoning S~rcharge (15.00 ffappllcable) <br /> <br />E, Other insl~Ctlon~ not Jlst~c[ <br /> ~ 40.00 l~r hOtl~ (2 hour minimum) <br /> <br />@ $60.00=__ <br /> <br />(a) $4000=__ <br /> <br />TOTAL= $ ~Yl~.~O <br /> <br />I he.by certify that the above iuformafirm is correct 'a~ld that I hav~ read and understand the Information Notice to Property Owners about Construction Responaibilhies <br />on the mverae side of this form. <br /> <br />fhis fee cOVerS the manufactured stmcum placemen, plumbing eomnectim, electrical connection and meehanica eonBection, Site evaluation, septic permit, electrical <br />service or plumbing wear/sewer lines are ~eparate required permits. MC 15-64 Rev 11-91 <br /> <br /> <br />