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<br />MARION COUNTY BUILDING INSPECTION
<br />
<br />FOROl"F~LY 220HighStrwiNE
<br />Received by: Salem, OR 97301
<br />ZoningValidatiOD; 2;.~' 8:00¿:-41~Ph,~::1147
<br />Date: ~-2::t-_~ eiAXS';';794Š
<br />MANUFACTURED'STRUCTUREPLACEMENT
<br />COMPI-ETE ALL SECTIONS, I TIiROUGH 4 PERMIT APPLICATION
<br />L Job Deseri lion
<br />
<br />FOR OFFICE USE ONLY
<br />
<br />
<br />qCJ- \20r\~
<br />
<br />
<br />ResidentialO()
<br />Commemia1( )
<br />
<br />New9«,)
<br />New( )
<br />
<br />Year of
<br />Manufacture:
<br />
<br />Ii I hire sul><:<>nlmOlo", I will hire only subcootrnctors registered with the ConsttUction Contractors Bo,m!. \.
<br />liIchange .nymind, ~d ~o hire 'a generalèon"';ctor, I will contraet J;th . cOntractOr wbo iire¡;istcredwhh'the Cons/rnction Contractor's Booed, and will
<br />inunediatelynotify'ManonÇountyofthenameofth<cootractor, ' '
<br />Contractor Busme" Name & U
<br />
<br />
<br />nS-
<br />
<br />4,Fee Schedull;:
<br />A,
<br />
<br />orModularUnhPI..cmcntJÇonoection @ ~.~OO
<br />(2) >"ateF.. @ 20,00~~-'
<br />
<br />(3) Slalc Surebaq¡e c.;io",. f). n. '@ -'~. = -?LJ.; ÇO
<br />(4) :b....~n.sn,,!,".."(!-3,OO"4~'@ ::;:r;:~-s:-'
<br />
<br />roTAL:$~'16"
<br />
<br />C, Addit;"'..! Impection
<br />or Rcimpoc'¡on
<br />
<br />@,) $60,(X ~_-
<br />
<br />D, Investigation!f«
<br />
<br />ß, (1) Mrs,'d SttUCture Stomge Fee
<br />(2) Mfg,'d SlnICture Storage Renewal
<br />(3) 7Æ1ing Surcharge (IS,OO if applicable)
<br />
<br />@ $ 2S.00-----,-
<br />@ , 25,OO';~
<br />',@' IS,OO~----,-
<br />
<br />E. Other ",sp',,;ûons not liSled
<br />@40,OOperhou,(2hourminimum)
<br />
<br />@ $40,00"-
<br />
<br />TOTAL~ $
<br />I/a'f:.- ,.---
<br />RF,ÇEIPT: ~'t';;:,
<br />
<br />I bemby cenify thai the abo,," information is comct"". that I have ",ad ""d unkrstand the lnfmmation Notice '° PTOperty Owners .bout Cons'n>ction Responsibilities
<br />on the mverse ,ide of this fOITC, d' , '" ,4: 9t. 'X
<br />
<br />N,meofAppUe'I\t(pleas.prin.,9j. ,PIMP" ;:~,M6S Phone: (- '7i1' \
<br />
<br />Sig"",u",ofAppJi«nt: C'~ (~ D"e, ~-/¥-q.!,,~
<br />
<br />Tbi. fco cove," the m,n<lf".,u",. "tUctum pl,,«menl. plumhing coonection, electric,] eonn«tion ""d m«hanin'l connection, Site ev,lo.tion. "'ptie P°'ffiit, deotrie.!
<br />.e<vine 0< ph'mb;n. w"tc</æwc< lines ,re separe'" requ;md pe'ffiits, MC 15-64 Rev ! 1-91
<br />
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