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MARION COUNTY BUILDING INSPECTION <br /> <br />FoR' )FFXC E ONLY I ,'' ~:o HighStxeetI ,, <br />Received by: &~f ~- ~ ',:.: '. S~em, OR 973~//,~ '~,<~ -~ <br />- , + · ~ ff >' 8~am-43~m~ g~ ~'~ ~<':', <br />Date: ~ ~ q~ '" [ F~588-7948 TM ~i~~ <br /> ....... MANUFACTURED STRUCTUREP~CEMEN~ ~ <br /> CO~TEA~$ECqlONS, 1TI~OUGI-I 4 PER~ APPLICATI~ ~ ~ ~{ ~ <br /> <br />FOR OFFICE USE ONLY <br />(~ty Setbaak Requirements: <br /> <br />Front; /~0 / Rear: /0,,,,/ <br /> <br />1, Job Description <br /> <br />Commerdal( ) New() Replacement() <br />M~actu~s Year of Color ~ <br /> <br />2. Location of Installation ... <br /> <br />Job Aaa~ ! / S- O ~ r ~ e. I 't> ~ .... x~ Acco ~o. cross s~,[ ~C,~ ~ <br /> <br />fiub~vi~n .................. L~ {~i~ Urban Growth Bounda~? <br /> Pfivat~ We~ ( ) Spring <br />L~Wid~ ~' / ............ ~Ve~h q~ ' Acres ........... ~g.~t ~ Comet ~O CommutfityWegq ) City <br /> <br />3. Contractor Information <br /> <br /> ) I o~, ~s~e ~, ~ ~ reside ~ the ~m~e~d <br /> <br /> ) I anders~nd ~at I must m~smr as a c~st~ con~r ff ~e stream is sold or ~emd for sale b~om or u~n cmplefion, <br /> <br /> ) I wffi ~ my o~ g~er~ cont~or, <br /> <br />ff I him subcontractors, I will hire only subcontraetor~ registered with thc Construction Cemractor~ Board, <br />If I change my m~d and do him a General contractor, I will contract with a omtractor who is r%dstemd vAth the ConitmcLion Contractors Board, and wilJ <br />immediately nofiI-y Mafirn County of the name of the contractor. /tJ~ ~- ~ <br /> <br />( s~j~l am a reglstemd hailder~l~ th~aathofi~res~tative of a reglstemd builder, WOt ~tt;~ O']3'/ <br /> <br />4. Fee Schedufl~ ~ ?c~'~- <br /> <br />A. (1) Manufactured Home <br />or Modular Unit PlacemmffConnectlon @ $182.00 ~ <br /> (2) State Fee @ 20.00= ~.~ <br /> @ 9,t0-- 'LiD <br /> <br />B, (1) Mfg.'d Structure Storage Fee <br />(2) Mfg.'d Structure Storage Pmnew~l @ 25.00 =_ <br />O) Zoning Surchalge (! 5.00 ff applicable) @ 15.00 -~ __ <br /> <br />C, AddLiionallnspeCfion @ $60,00 :=__ <br /> or Reinsl~,ion <br /> <br />D, Inveadgalion Fee <br /> <br />@ 40.00 per hour (2 hour minimum) <br /> <br /> $40.00 <br /> <br />RECEII~I': <br /> <br />hereby ceaify that the above information is comet and that I have read and underatand the Information Notice to Property Owners about Construction Responsibilitle~ <br />on ~he reverse side of this form, <br />Nameol'Applicant (plea~eprint-~L/ ~ t~e~- Phone' F/~-)~c; <br /> <br />'I'~s £C~ cOVcrs~ac, Ire; sin ¢/; p]Lme~t.;,umbing~'~corm,cfico, e]ectlS.¢a] cormectJ, on ~nd meehathea, connection. Site ,valuati0, .svp i permi .elec r/cai <br /> <br /> <br />