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FOR OFFICE USE ONLY <br /> <br />Received By:: <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 High Street NE <br /> Salem OR 97301 <br /> <br />800am-430pm Phone588-5147 <br />Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> FOR OFFICE USE ONLY <br /> <br />Front:: <br /> <br />Left Side:: /~ ~.,[ <br /> Rioh Side:: <br /> <br /> MANUFACTURED STRUCTURE & SEPTIC PERMIT APPLICATION <br /> <br /> [/~ Single Family Dwelling [ ]O~ce [ ] Classroom [ ] StOrage <br /> [l~'~S [ ]COM [IdNew [ ] Storage [ ]Occ. Chg, [ ]Replacement [ ]TechnicalReview <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH zl <br /> <br /> 1. Location of Installation <br /> <br />2. Installation <br /> <br />4. Fee Schedule <br /> <br />3. Septic Information (Check where applicable) <br /> <br />PmposcA No,, B~rc, ana: Exastmg No B~: New <br /> <br />~ Si~ Ev~uafi~ <br />'l~t lldm Ra~ ~ Wffi ~ ~en T~ Holes <br />E~g Sim gvM~t ~ ~s~ ~ Ev~u~ No:: <br />P~scd ~s~ation Penm[ <br />Ex~fing Septic$ys~n ~ ~ ~ ~ ~ <br /> <br />EMsung L.'mnfield I~gth, <br /> <br />Date Tm~ L~st Puml~:: <br /> <br />Pumper Ponn Agl~chea [] <br /> <br />d ~(.~ecectl, othe~tofmyknowledge BUILDING INSPECTION <br /> <br />[/4""The woflc will be perforated by a registered builder,, <br /> <br />Each M~ 'd Hozne or Modular Und <br /> <br />ElectricM Semite ...... 35~ <br /> <br /> (1) 7 otol of Above Fees $ <br /> (2) 5% State Surchame <br /> <br /> Subtotal <br /> <br /> B Mfg 'd Structure Storage Fee 25(×1 <br /> Mlg 'd Structure Storage Rvmewal 25 <br /> S~te £valuation Fee <br />D Ne~ Septic In~tallauon Permit <br />E Authoriv.atiofl NoliceIee <br />F Repa[t Permh Fee <br />(10n,Sge Technical Review Fcc <br /> <br />II In'~c~tigataon Fcc (if required) <br />i Remspection Fee <br />J Other m~pcct[ong notlisted above <br /> (~ $4000 per hour (2 hour m/n) 40 <br />K City Fcc <br /> <br />TOTAl. AMOUNT DUI2 ~,~,.~ <br /> <br /> <br />