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MARION COUNTY BUILDING INSPECTION <br />FOR OFFICe/USE QNLY[, ,, ' ' ' 220 High Street I~ ~rea m ~.~OR OFFICE USE ONLY] <br />Reeeivedby: [~'~ ~ ~ "" Salem 0R97301~.[~'{~1~[~)[~o.i~ <br /> <br /> COYOTE ALL SEC~ONS. 1 TI-mOUGH <br /> <br />:2. LocafionoflnstallafioB q Tz23- <br /> <br />3. Contractor Information <br /> <br /> ) I o~, msMe ~, or ~ ~sid¢ ~ the competed stmcm~, <br /> <br /> ) I under,nd ~at I must m~smr as a constmc~ c~etor ff ~e stm~u~ is sold or offered for sale before or u~ empletlon. <br /> <br /> ) I wi~ ~ my own gme~ ~tra~or. <br /> <br />If I him subeomracmr~. I will him only subcomra¢[o:~ registered with the Consumaion Contractors Board, <br />If I chang¢ my mind and do him a gcnerul contractor, I-Mll contract with a ¢omraetor who is registered with the Constmetlon Contracm?s Board, and will <br /> <br />immediately no,fy Marion County of the name of thc contractor. __ . <br /> <br />( b~aam a mgisthrod builder OR thc authorlr,*d ff~pr~sexitalive of a mgist.~d builder. <br /> <br />4, Fee Schedule <br />A. (1) Manuhcmmd Home <br /> <br /> or Modular Unit Plaeem~mt/Conn¢OJon <br /> <br /> (2) State Fee <br /> <br /> (3) State Surcharge <br /> <br /> (4) Zoning Surcharge (15,00 if applicable) <br /> <br />B. (1) Mfs,'d Structure. Swrage Fee <br /> (2) Mfg,'d ~txuemm Storage Renewal <br /> <br /> (3) Zothng Surcharge (15.00ifapplieabl~) <br /> <br />I hereby certify that the above information is correct and that I have read and understand the Information Notice to Property Owners abou~ Construction Responsibilities <br />Name of Applicant (pteaiejlrJ~)t,~ ~'/~/~-~/'~/~.~Aff/;~ Phone: .~? ~ ~ ~ <br /> g PP ~ ;., · - ,~,~'.5/;/ ~'"'~-'~'~ .... Date: ~ <br /> <br /> MC 15-64 Rev 11-9I <br /> <br /> <br />