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COMIaLETI~ ALL SECTIONS, 1 THROUGII 4 <br />1. <br /> <br />MARION COU <br /> <br /> MANUFACTU <br /> PE <br /> <br />COmmercial,( ) New( <br /> <br /> ye. ar of <br />Serial #: Manufacture: <br /> <br />2. Location o£ Installation <br />Pml~rty Owner <br /> <br />Subdivision <br /> <br />Lot Width ,~..~ / Lot Depth <br /> <br />NTY BUILDING INSPECTION <br />220 High Street NE [,FOR OFFICE USE ONLYI <br />Salem, OR 97301 <br /> <br />Code-A-Faone588-790~'%.'', ~% :~ ~' ii ~L:~ }7~.,~}k~ i.., ....... c "'1 <br /> F~588-7948 ~/ ~ ~ ~ ~ ~°m~:lq~ Imgmm~e' to I <br /> ED STRUCTURfl g~ACEMENT <br /> ~T APPLICAT~ <br /> <br /> Rephcemmt( <br /> P~placement( <br /> <br />Color of <br />Approved <br /> <br /> Sq, F~ovage.: <br /> <br />) ~,~ARION COUt~a~°LCaTo~ <br /> <br />Tax Acer, No. <br /> <br />Sim No- <br /> <br />Length:~l~9 ~ <br /> {No.;Bedrooms: <br /> <br />Vho.e No, <br /> <br />j Block <br /> <br />¸Map <br /> <br />Irreg. L ot .ff~ Comer <br /> <br />Urban Growth Boundaly? <br /> <br />Y( ) N( ) <br /> <br />Wamr Supply: <br />PfivateWeti ( ) Spring <br /> <br /> 3. Contractor Information <br /> <br /> ) I own. t~$ide i~, or will x~fid¢ in the completed atmetu~. <br /> <br />( ) I under~talld,that I mU~t n~gi$~r as a const~Jetinn contractor if [ <br />( ) ~ wLll be my own geo~tal ~ontraetot, <br /> <br />, I Phone No, <br /> <br />immediately noffy Marion County of the name of the contractor, <br /> <br />4. Fee Schedule ., / , , ,, <br /> <br />A, (1) Mmmfacxured Flame <br /> <br /> or Mode[ar Unit PlacexnenffCorm ection <br /> (2) State Fee <br /> <br />@ 25.00 =__ <br />@ 15.00 =__ <br /> <br />C, Additional l~spection @ $60,00 ::~ <br /> <br />D, Iavestlgat[on Fe.e <br /> <br />@ 40,00 per honr ¢2 hour minimum) <br /> <br /> (3) State Surcharge <br /> <br /> ¢) '~ . ,,, .............. <br /> <br />B, (1) Mfg.'dStmcturoStoragaFt~¢ <br /> (2) Mfg,'d Structure Storage Renewal <br /> <br /> (3) Zoning Surcharge (15.00 ffappli~able) <br /> <br />l hereby certify that the above information is correct and that I have mad: <br /> <br />~a · ~pp c nt~pm-~, .~ .Z~.~%. /~/' ~---. - . ,, <br /> <br />MC 15,64 Rev 11-91 <br /> <br /> <br />