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MARION COUNTY BUILDING INSPECTION <br />FOR~ OFFICI~ USE Ol LYI 220 High Street NE FOR OFFICE USE ONLY.1 <br />Received by:..~~_ / ~ Salem, OR 97301 laity set~¢k Re~oir~nen~: / <br />Zoning ValidationS. [ s:oo mn-4:30pm Phone 588-5147 [ Front-. /O / I Rear'. /.~-'/ <br />Date: <br /> FAX 588-7948 ~;~ ~.~.~ ~ <br /> <br /> COMPLETI~ ALL SECTIONS, 1 Th'ROUGH 4 PERMIT APPLICATION ~ ~.z ....... * <br /> <br /> 1. Job Description ' 3 2 ~ , <br /> <br />2. Locafionoflng~l~fion <br /> <br />s~¢lim Yownshp ~nge Zm* ~ Map Wafer Su~iy: <br /> ............. Private W~ ( ) Spring <br />~[Wid~ ~5-/ ~Depth ¢~ A~m, ......... lffeg,~t~O Comer ~ ..... Commun~trwen( ) cit~ <br /> <br />3. Contractor Information <br /> <br />(~) I own, reside'in, or~v~l[ msia, in ~he complemd s~rUC[um. ' ' <br />( ) I under~tand that ~ must ~gisl~r as a ¢ons[ru¢fic~ contractor if the structure is sold o~ offexed for sale before or upo~ ¢onxple[ion. <br /> <br />( ) I will be my own general contractor. <br /> <br />Ii I him subcontractors, I will hire only sub~ontraetom registered with the Construction Contractora Board. <br /> <br />If I Change my mind and do Mm a general Contractor. I will contract with a contractor who i~ reg~*te~d with the ConsLetletion Contraetoes Boa~, and will <br />immediately notify Marion County of the name of the contractor <br /> <br />< K) am a reglatere, d b.lldef OR the relxes;ntariv¢ or a heildex, <br />4. lee Schedule <br /> <br />A. (1) Manufaetared Home <br /> or Modular Unit Placement/Cornice'adh <br /> <br /> (2) State'Fee <br /> <br /> (3) State Suvaharge <br /> <br /> (4) Zoning gu rcha~e (15.(30 ff applicable) <br /> <br />B, (1) Mfg.'d Structure Storage Fee <br /> @ $25.00=,__ <br />(2) 3/ffg,'d Structure Storage Renewal @ 25,00 = <br />(3) Z~nlng Surcharge (I5,00 if appl.[¢able) ~ 15,00 = <br /> <br />C- Additional Insp~on <br /> or Rcinspeeaon <br /> <br />D. Investigation Fee <br /> <br />~. Other insf~¢tions not listed <br /> @ 40.00 per hour (2 hour mi~dmum) <br /> <br />@ $60.00 <br /> <br />RECEIPT: <br /> <br />SgnaumofAppeat [2~7 ,-~I,~.~ O,,e-Am. 2 .tq4q <br />MC 15-64 Rev ]1-91 <br /> <br /> <br />