Laserfiche WebLink
FOR OFFICE USE ONLY <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 220 High Stree. I.~E .e~ <br /> Sa[em, OR 9~'~ <br /> <br /> Code-A-Phone 5'ff~-Tg04 ~.~ FAX 5W3-7948 <br /> <br />FOR OFFICE USE ONLY <br /> <br />~. i t'yl~ ack Requirements: <br /> <br />Left Side: /~ Right Side: /~? / <br /> <br />MANUFACTURED STRUCTURE & SEPTI~,~._ I'~[.ICATION <br /> <br />[b'] Single Family Dwelling [ ] Office [ ] Class'room [ ] Storage <br />r ta'/R' s ti eom tt.r' mw [] Storage ti O=.Chg. <br /> <br />[ ] Replacement <br /> <br />[ ] Technical Review <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Location of Installation <br /> <br />2. Installation <br /> <br />Auth. Agmt/I~.a~iu~ <br /> <br />JCoa~,~etc~ Business Nnme & Number Mailing Addre. ss & ~e Na <br /> <br /> I~np~r Form Attached [] <br /> <br />{ ~I have mad this application in its cnfitet~ and cetlify that the stated ilffotmati~ is LInC agld <br /> <br /> ct Io thc best of my knowlexlge. <br />[ ] I~lx~ffofmingworkonapropcttylownorocc~py. <br />[D]/I~am-aregistete, dl,m/lder OR [ ]theauthoIizedmpre~tiveofam~sm~dbuildet. <br />[ 1,,]/'l'ne w~rk will be performed by a mSlste~ baildm-. <br /> <br />[ [~agnm to build according to ~ submitted plan~ and ap~catio~s, th~ hws of thc <br /> state of Oregon and the VT.~s of Ma ,lion C,o~mty/ <br />Signature of Applicaut ~ <br /> <br />4. Fee Schedule <br /> <br />A. Each Mfg.'d Home or Modular Unit <br /> <br /> Each Mfg.'d Home or Modifier Unit <br /> <br /> (1) Tolal of Above Fees ~,~' <br /> (2) 5% State Sumharge (.05 x Al) ~, / O <br /> (3) Zoning Suwharge (,05 x A 1) <br /> Subtotal &~//, / O <br /> <br />13. Mfg,'d Structure Storage Fee 25.00 <br />Mfg,'d Structure Storage Renewal 25,00 <br />C. Site gvaluafion Fee <br />D, New Septic Lnsmllation Permit Fcc <br />E. Authorization Notice Fee <br />F, Repair Permit Fee <br />G, On-Site Technical Review Fee <br />H. Investigation Fee (if required) ........ <br />I, Rein~pection Fee <br />J, Other inspections not l[s~¢d above <br /> @ $40,00 per hour (2 hour min.) -- 40.IX) <br /> K, City Fcc Q, / O <br /> <br />TOTAL AMOUNT DUE <br /> <br /> <br />