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FOR OFF [y S. oNLYI <br />Received by!/~[t vv~c~ <br />Zoning Val~atiom~ <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem,OR 97301 <br /> 8:00 am4:30pm Phone 588-$147 <br /> Cod,-A-Phon~ 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED: STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLETE ALL SECTIONS. 1 THROUGIt 4 <br /> <br />1. Job Description ._~_. <br /> <br /> FOR OFFICE USE ONLY_] <br /> City Setback Requirements: J <br />[ Front: 2-~ t [Rear: ! ~" r j <br /> <br />2. Location of Installation <br /> <br />Pint'ay Owner Mailing Addre,s ' <br /> Privaxe W~ ( ) Sp~g ( ) <br /> <br /> 3, Contractor Information <br />I yOwner ]'3a iAda, . [Phone No, <br />i ( b'~ own. reside in, or wffi reside ~ ~e ~plemd s~+ . <br /> ( yI ~de~mnd ~at ~ must m~Smr as a ~$tm~ ~n~c~ ff ~e s~m ~ ~old or ~emd for sa~e before or u~ <br /> <br /> ff I ehmg~ my mind ~d do Mm a g~ ~aemg I ~ ~<t wt~ a ~c~r w~ ~ m$~te~ wi~ ~e Cons~cfion Conmctots Board, and wi~ <br /> <br /> ( ) I ~ a ~g~sm~ builder OR ~e au~o~ ~s~fi~ ~ a mg~s~d b~der, <br /> <br /> 4., Fee Schedule ·: <br /> <br /> ' '0) ..... : <br /> (4) ~ <br />B. (1) Mfg.'d Structure Storage Fe~ <br /> ¢2) Mfg.'d StrUcture Storage Renewal <br /> <br /> O) Zoning Surcharge (15,00 ff applieabl~) <br /> <br />@ $40,00 <br /> <br />TOTAL= <br /> <br />I hereby certify that the above i~otmation is correct and that ~have ~:an8 understand the Information Notice to l'ropergy Owners'about Const motion Respon sibLlifies <br />on the reverse side of this form. <br />Name o£ Applicant (please prillt ). ,~a~o4'- ¢ ~ <br /> <br />'Il'ds fee covers the manufactured str~ctuf~ pla~ment, plumbing connection, electrical connection and rnechanical connection. Site evaluation, ~cptic permit, electrical <br />service ct plumbing water/sewer lines am separate required permits, <br /> MC 15.64 Rev I1-9I <br /> <br /> <br />