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MARION COUNTY BUILDING iNSPECTION <br />;' FOR~JFFIC/~Y$~EI, 220.,h I oR OFF,C , US . O LY1 <br /> ~e~ived by:~ Salem, O~730~, . ~[~ S~ Requests: 1 <br /> <br /> MANUFACTURED STR~URE PLACEM~Z ~ ................ <br /> CO~[~T~ a~r sec'no~s. ~ T~mOU~n 4 PER~T APPLICAT~ 0 0 ]~g <br /> 1. Job D~cripfion <br /> <br />2. Location of Installation <br /> <br /> f2kz~,..~,/Zo_ ~,,,7-;'.~5- si,,No,. ..... <br />8uMivism Lot I BI~ ............. Urban Gmwtd' Boundaw? <br />.... ~;;'~,~om~,~ ~ ~' s~=~ ~3 ' ~ ~ ~( ~ <br /> .................... Comma~[y Wdl( } Cit7 <br /> <br />3. ContractOr Information <br />~YOwn~/J&¢~-~ ¢-~ ~ IM~i~^da== '1~°*~°' <br />( ) I om, reside in, ~ <br /> <br />( ) I ~ be my o~ g~et~ <br /> <br />~' I hke sob~ntracto~, I MIl h~m only subcm/mct~ reglster~ wj~ ~e Constm~im ~mr~ goard. <br /> <br />~ I ~mge my m~d and do him a gem~ ~cmr, I ~11 ~mm~ wi~ a cmuacmr who is m~sm~d wi~ ~e Cons~cfim Contractor's Board, md wi~ <br />~edlamly no~y Marion Comty~f the name of <br /> <br /> Con,actor Bu~ess Name & ~: Ma~g Address' ' Phone' <br />( ~ I am a regi~mmd buader OR ~ au~od~d re~sen~aw of a registered b~Idcr. <br /> <br />4. Fee Schedule <br />A. (1) Manufactured <br />~ Medlar Uni~ Ph~ffC~ne~ ~ $182 00 - /~ ~ C. Addi~al ~spec6~ (~ $60.~ :: <br />(2) Stat, Fee ~ 20:~ ~ ~ ~ or Rdm~mio~ <br />(3) State Surcha~e <br /> <br /> f ' ~ 40.00 ~r hoot ~ hour minimum) <br />g. (I) M g. d Sin crum S orage Fee <br /> <br /> ~) ~g.'d S~cturc <br /> <br /> (3) ~ning Suicide (15.~ if applicable) <br /> <br />@ $40.00 =____ <br /> <br />on die reverse side of this form. , <br /> <br />Sgnat <br /> <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />