Laserfiche WebLink
FOI{ 6FFICE USE ONLY <br />Received by:- <br />Zoning Valldationa <br />Date: <br /> <br />MARION COUNTY BUIL~G.'~q;N..~,Plg~Q~ -~ <br /> 220 High Str~~g (~ i~ ~ 1~ I~I I~0~ OFFICE USE ONLY <br /> Salem, OR ~3¢1 I ~bt~ck Requ[~ents: <br /> 8~ m.43~a588-514~ ~ ~-, ~0~ ~ ~a'r' ' ....... <br /> C~e-A-~one~88-7904 .... ~ ~ / t,~>'ff} ' . ' . <br /> [ L~t S~e: [~ghl Slge '. <br /> <br /> FAX 5118-7948 <br /> MANUFACTURED STRUCTURE~0~'E~]-¥ <br />COMPLETE ALL SECTIONS. 1 THROUGH 4 PERMIT APPLIC~!~ <br />1. Job Description <br /> <br />Re~identiaI(~X*~) New( ) Replaeement(~) enrage or Carpoa <br /> ( ) At.&ed <br />Comme~al( ) New( ) R~hcem~t( ) (~) Detached <br /> <br />manafacm~ffs Year of Color of LagS: /Widta~:~,/ <br /> <br />2. Location of Installation <br /> <br />3. Contractor Information <br />Pm~eI~y Owner ~ I MaiJ~g Address f~/~A~ Iph°~ N°i, ~/~/?~' <br /> <br />(~) I understand ~at I must ~g~ster as a ¢oastm~ conta~or d ~e s~ is aold or offered for s~e before or u~n e~pletoa, <br />(~) i wiR be my owe general coat raaot. <br /> <br />immediately hefty Marion County of the name of the contractor. <br /> <br />Con actor Busmess Name & #; [ Marling Address: [ Phone: <br />( ) I ava a registered builder 01~ file authorized fept~sentafiv~ of a registered builder, <br />^uthoriz~.d ~g~nt or l~asee: ...... [Mal/ing Address: I Phone: <br /> <br />4, Fee Schedule <br /> <br />Ag(l) Manufactured IIome <br /> <br /> or Modular Unit Flacememt/COnne6~ion <br /> <br /> -¢(2) State Fe~ <br /> ¥0) State Surcharge <br /> \[4) 7xming Surcharge (15.00 if applicable) <br /> <br />B,~l) Mfg.'d S/rectum Storage Fee <br /> <br /> (2) Mfg,'d Stmcmm Storage Renewal <br /> <br /> X{3) Zoning Surcharge (15.00 if applicable) <br /> <br />$182.00 ~__ C. Addlrional ~spec~on <br />20,00 =__ or Reinspeefion <br />9.10,~- I <br />15.00 = ~ D. ~ves~afion <br />qDTAL: ~ <br /> ~ 40.~ ~r hour (2 hoar mimmm) <br /> <br /> 15.~=~ <br /> <br />@ $60,00=__ <br /> <br /> (~ $40,~ = <br /> <br />RECEIIrf: <br /> <br />i hereby certify that the above information is coffee; and [hat I have mad and undemtand the ialformalion Notice to l:'ropcny Owners ab( Cons ruc ion Respons > ] tics <br /> <br />Name of Applicant (please prlnt)'> ~7,~/'~ff ~ ~' ,,Phone:(f~ / ~ .~'~7 <br /> <br />service or plumbing water/sewer lines am ,~eparate required pcmtits. MC 15-64 Rev I 1-91 <br /> <br /> <br />