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IFOR OFFICE USE ONLY <br /> Received by:. <br /> Zoning Validation;, <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br />8:00 am-4:30pm Phone 5554147 <br />Ced~A-Phor~ 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PER/~gT APPLICATION <br />COMPLETE ALL sECTIONS, 1 THROUGH 4 <br />1, Job Description <br /> <br />FOR OFFICE USE ONLY[ <br /> <br />2, Location of Installation <br /> <br />Mailing Addmsss Phone No, <br /> <br />MobiLe Ilore¢ park <br />Scot/on 'lbwnskip <br />Lot Width LO~ Depth <br /> <br /> Block <br /> Space # <br />Range ~ Zone Map <br />Aere~ ~ Irreg. Lo[ Comer <br /> <br />Pdvate W~ll 0% Sprblg ( ) <br /> <br />3. Contractor Information <br />Property Owner [ ~ailmg Adams} {1'hone No. <br />('~) I own, reside in, et will reside in the completed sgmoture. <br />( ) I understand thal I must register as a construction contractor ff lh~ structure is sold or offered for sale before or ~pon completion, <br />( ) l will bc my own gatcral cOx*tractor <br /> <br /> hire subcontractors. I will him only subcont rectors registered with the Constmetiotl Contractor~ B~rd. <br /> <br /> ch~ge my mind and do hire a gentml ~ntmcmr, I Wi~ mnkact wi~ a c~tmcmr who is m~stemd with the C~otio~ Contractors Boa rd, and wi~ <br />in~edlately no~y Marion Coanty of thc name of ~¢ contractor. <br /> <br /> ntractorB, slnc~Name&~: } Ma~g Address: ~I <br /> ) I am a mgismmd builder OR ~e au~ofi~d tepmsenmfiv0 of a regismmd <br /> <br />Au~ofi~d agent or lca~ea: IMa~g Address; ~ Phone: <br /> <br />4. Fee Schedule <br /> <br />A, (1) Manufaetmed Horee <br />or Modular Unit Pla¢¢reent/Conneclion @ $182,00 = -- <br />(2) State Fee @ 20.00 = <br /> @ 9.10 =__ <br />('3) State Surcharge @ 1S.O0 =__ <br />(4) Zotting Surcharge (15,00 if applicable) <br /> TOTAL: $ ~,~ ~ <br /> <br />(I) Mfg,'d Structure Storage Fee <br /> @ <br />(2) Mfg.'d 8traeture Storage Renewal @ 25,00 =__ <br />(3) 7aorting Suteha~3e (15,0O if applieable) @ 15.00=__ <br /> <br />C. Additional Inspection <br /> <br />D. ~vestigafion Fee <br /> <br />E- Other inslg~Ct, lons not listed <br /> @ 40.00 per hour (2 hour min/reum) <br /> <br />(a) $60.(×)=__ <br /> <br /> ~p $40,00 <br /> <br />TOTAL= <br />RECEIFI': <br /> <br />MC 15.64 Rev II-9I <br /> <br /> <br />