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.MARION COUNT; <br />' FOR OFFIC//E~U~SE,z?NL_Y x/ :20aig~S~t~fi~ ~ffV,~FICE USE ONLY{ <br /> Received by:~ ~1 ~ / S~em, OR 97301 <br /> <br /> [Date; / ~-~5 ~ ~e-A-~m~ 588-79~ <br /> <br /> MA~FACTURED STRUCTURE <br /> <br />SaMivision <br /> <br />Lot I Block <br />swoe# ~ / <br /> <br />h~,kot /~/# Comer <br /> <br />Urban Growth Boundary? <br /> <br />Y( )N( ) <br /> <br />PfivateWell ( ) $prjJ~g ( ) <br />~9~UnltyWell( ) C ty (1~ <br /> <br />3. Contractor In£ormation <br />PropertyOwner~.r. ~q~¢/ ~ J Mailing Address JPhoneNo. <br />( ) I own. msid~ in, or will n~sidc hx thc completed stru(zure. <br /> <br />( ) I understand that I must register as a construction contractor ff thc structure is sold or offered for sale before or upon completion. <br /> <br />( ) I will be my own 8enera! col~tractor : <br /> <br />immcdiawdy no~y Ma#on ¢oung, of the name of llie contracior. O ~t~,$'4/? ' <br />Contr,.~orBu6nessNamz&#'x~d~t~g[~ffl~ll~f~& JMailmgAddm:s: ~,~ ,*.t ~'~aV-~.-I l'hone: <br /> <br />4, Fee Schedule <br /> <br />A. (1) Manufactured Rome <br /> <br /> or Modula~ I.lnk PlacemmqCormexiion <br /> <br /> (2) State F~ <br /> <br /> (3) State Surchalge <br /> <br />g, (1) M£g,'d Stmcmm Storage Fee <br /> (2) Mfg.'d Stmcmm Storage Rcn0wal <br /> <br /> (3) Zoning Surcharge (15.00ffapplioable) <br /> <br />$182,00= [~,~,ff'~ C; Additionalhspeetion <br /> <br /> 930= q,l~ ; , ' ,:' ": <br /> <br />40,00 per hour (2 hour minimoxn ) <br /> <br />@ $60,00 ~__ <br /> <br />@ $40,00 <br /> <br />@ <br />@ 2f00 =.__ TOTAL = $ ~,~3/~. ~0 <br />@ moo _-__ / 7q.-d...? <br /> RECEIPT: <br /> <br />I hereby certify that the above information is correct and that I have ~ad ~md understand the Information Notice to property Owners about Cc~lst, n etlon Respon ~ibilifies <br />on the reverse side of this form. <br /> ~~ ' C. ~.9/~ Ph 7d~-77~5 <br />Name nf Applicant (pie one: <br /> <br />service or plumbing waif/sewer Iines are ~eparate required permits. MC 15.64 Rev 11-91 <br /> <br /> <br />