Laserfiche WebLink
FOR OFFICE USE ONLY <br />R, eceDed by: <br />Zoning Validation: <br />Date: <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> COMPLETR ALL SRCTIONS, ! THROUGH 4 PERMIT APPLICATION <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 High Street Nli FOR OFFICE USE _ONLY <br />Salem, OR 97301 I City Sethaek Requlremegts: [ <br /> 8:00 am.4:30pm Phone 588-5147 From: Real: / <br /> Code-A-Phone 588-7904 Left Side; l~ight Side; <br /> } <br /> FAX 588-7948 <br /> <br />1. Job Description <br /> <br />Resident~l( l~ New( i/) Replaeemmt( ~ Garage or Ca~ <br /> ( ) Atmched <br />C~mcr~( ) New( ) Replaeem~ ) ( )Detach~ <br /> <br />Manufa~um~ Year of Color ~ I.mg~: Wide: <br /> <br />2. Locafionoflnsmlhtion <br /> <br />Lot Depth <br /> <br />Acms ~ <br /> <br />Phone No. ~/-OC~..~2_~ / O O.y <br />Cross Street <br /> <br />P:/vateWell (l~f~Sprlng ( ) <br />Commurdty,Wel( ) Cry ( ) <br /> <br />Urban Growth Bounda~,? <br />Y( )N( ) <br /> <br />Zone Map <br />Irreg. Lot Comer <br /> <br />3. Contractor Information <br /> <br />(~) I own, ~side ~, ~ wffi reside ~ ~e c~plc~d structure. <br /> <br />( ) [ BB~ ~a[ I must ~s~r as a eomt~cfi~ c~etor ~ ~e stratum is sold or offered for sale before or u~n compleilo0. <br /> <br />( ) I wi~ be my om gmer~ c~tmao* <br /> <br />C~mtractor Bus,ness Name & #: ] Mail/rig Address: ] Phone: <br />( ) I am a registered builder OR the authorized ~pre~entative of a registered boildef. <br />Authorized agent or leasee: [Mailing Addless: .... I Phone'. <br /> <br />4. Fee Schedule <br />A. (1) Manul'acmred Home <br />or Modular Unlt Plaeemea~t./Conneefion @ $182.00 -- __ <br /> (~) State Pee @ 20.00 = -- <br /> (3) State Sureha~e @ 9,10 ~- -- <br /> @ ts.0o =__ <br /> (4) Zoning Surcharge (I5,00 if applicable) <br /> <br />'iDTAL: $.__ <br /> <br />B. (1) Mfg.'d Structure Storage Fee <br /> @ $ ~5.oo <br /> (2) MZg.'d Structure Storage Renewal @ 25.00 <br /> (3) Zonlng Surcharge (l 5.00 if applleable) @ I5.00 =__ <br /> <br />C. Additional Impcetion <br /> or Re-lmpecfion <br /> <br />D. Invesilgatio, <br /> <br />~. ethel' inspections not hated <br /> @ 40.00 per hour (2 hour mixtimlma) <br /> <br />@ $60,00 <br /> <br /> (~ $4000=__ <br /> <br />TOTAL= <br />RECEIPT: <br /> <br />I hereby certify that the above information is correct and that I have mad and understend the lMormation Notice to Property Owners about Constmctlon Responsibilities <br />on the m~yeme side of this form. <br /> <br />Name of Applicant (please print): .Phone; <br />Signature of Applieanl; Date: <br /> <br />Tiffs fee covers the manufactured structure placement, piffmbhag connection, electrical eonneetlon and mechanical connection. Site evalaation, scptle permit, clecte/¢al <br />service or plumbing water/sewer 1/nas are separate requi~cd permits, <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />