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MARION COUNTY BUILDING INSPECTION <br /> 220 ~gh Strut NF. <br /> Sal~ m, OR 97301 <br /> 8:lDO am~!30Pm Phone 588-$147 <br /> <br /> FAX 585-7948 <br /> MANUFACTURED IsTRLICTURE PLACEMENT <br /> ', 4PERMIT ~PPLICATION <br />COMPLETE ALL SECtiONS, 1 {HROUGR ,, <br /> <br /> FOR OFFICE USE _ONLY/ <br /> City Setback Requirements: / <br /> <br />[Left~do:/~ ! IRight Side'' /~' i <br /> <br />2. Location of Inst~!!~tion ' <br />Prol~tty Owner Phone NC,. 7 <br /> <br />Block <br /> <br />3, Contractor Information <br /> <br />( ) 1 o~. ~side ~, or ~ re{ldo ~ the ¢mple~d s~, [ <br />(~) I unO.md ~t I must. <br />( ~ ) I ~R ~ my o~ g~l ~ontm~or. : , <br /> <br />Phone No. '7 [Cq-'7'7q~/ <br /> <br />a C~qtractotg Board. <br /> <br />and wi~ <br /> <br />Addr~sm <br /> <br />4, ieee Schedule <br />A, (I) Manufa~umdHom* <br />or Modular Unit Plac~mmat/Cormection <br />(2) State Fed @ 20,00-- <br />O) State Surcharge @ <br /> <br />B, (1) Mfg,'d Stmetu~ Storago Fee <br /> @ <br />(2) Mfg,'d Structure Storag~ R~ewal <br />(3) Zoning Surcharge (15.00 ffapplle, able) @ 15,00 <br /> <br />C. Addi~ional/mpeetlon @ $60.00=.~ <br />or Relmpeetlon <br /> <br />D, InvesfigafionFee <br /> <br /> B, Olher~spect~onsnot~sted @ $40.00=__ <br /> @ 40,00 tm- hOUr C~:ho~x ro~nimum) <br /> <br />· , , ~ TOTAL= ~ <br /> : R~CEIPT: <br /> <br />SignatureofApl211¢ant:- ~,,.~A.KI.Z~A ( ~. <br /> <br />MC 15-64 Rev 11-91 <br /> <br /> <br />