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MARION COUNTY BUILDING INSPECTION <br /> <br />Received b.y[ <br />Zoning Vahdat,on'.-O--~ ,/~ Salem, OR 97301 <br /> <br /> FAX 588-7948 <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> COIVlPLETE ALL SECTIONS, 1 TIffROUGH 4 PERMIT APPLICATION <br /> 1. Job De~cript/on <br /> <br />.,0R ()FFi~E USE ONLYI <br /> ty Setback Requirements: O ............. ] <br /> t: 0 I /') _l <br /> ImghtSm: <br /> <br />2, Location of Installation i~_.c~/- g 7~ ~-/ <br /> <br />Subdivision .-~.-:r~~ Lot [I~lo~k / UrhanG~o.~thl~o..aa,y? <br />Mobile Home Pa~ S~ce ~ Y(~ ) <br />Scan I To~shlp I D~ Ra.ge ~ Z~e ~ Map WaterSu~ly: <br /> ~ Private Well ( ) Sp~g ( ) <br />LmWid~ L~Depth Ae~s ~eg.~t Comer {~ CmmuNtyWd[( ) C~ X } <br /> <br />3. Contractor Information "' <br />property Owner [ MaJ~g Address {Phon~ No, <br /> <br />( ) I own, ~eside ka, or will reside in the completed streams. <br />( ) I understand that I must rebater as a constmct~c~ contractor ff the stmctur~ is sold or offend for sale b~ore or ulxm eomplet/on <br />: ( ) I ~ he my own' g~aeral cOntractor. <br /> <br />If I ~ subcontractors, I will hi~ only subcontra¢~ora registered with the Constmetinn Contractors Boar& <br /> I Change my mir8 an4 do hire a g~ral ~ntractOr. i will contract v~th a contramor who is mgistemd with the Constm~ion Contractor's Bo~rd, and will <br />immediately h0tffy Marion County of the n~m~ of the mntract0r. <br /> <br />ContmctorBusl~ess Name & #: [ Mailing Address: '1 Phone: <br />( ) I em a registered bu/lder OR thc authorized representative of a registered builder <br /> <br />Authorized agent or leasee: ................................ ]MaJ.l~lg Address: I Phone: <br /> <br />A. (1) Manufactured Home <br /> <br /> or Modular Unit Placement/Connection <br /> <br /> (2) State Fee <br /> <br /> (~) State Surcharge <br /> (4) Zoning Surcbage (15.00 i/applicable) <br /> <br />(I) Mfg,'d Struetur~ Storage Fee <br /> <br />(2) Mfg.'a Structure Storage Renewal <br />~) ~ <br /> <br />$182.00 ~ -- C, Additional Inspection <br />20,00 =__ or Ronspcot[on <br />9.I0=2 ~; .,:;: : <br />15.00 = -- D. Investigation Fe~c <br /> <br />@ $60.00 =__ <br /> <br /> TOTAL: $,__ E. Other Inspections not hsted Q? $40,00 = <br />@ 25.00= TOTAL~- $ (l~0 O0 <br /> <br />I hereby certify that tho above irdormatlon is correct and that I have teed and tmd~rstand the Information Notice to Property Owners aboot Constroetion ReslYon sibilities <br /> <br /> <br />