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FOR OFFICE USE 0NPY <br />Rec?ved by:~ <br />Zomng Validat~om <br />Dater <br /> <br /> MARION COUNTY BUILDII~INSPECTION <br /> 220 High Street I~J /~ ~ ~ ~/ OFFICE USE ONLY <br /> Salem, OR 973~[1} ~ ~ ~ :k Req~m~: <br /> 8:~ ~-4:3~m ~o~ 5~-~47 ~ear: <br /> <br /> MANUFACTUREB <br />CO~L~TE ALL SEC'lIONS. 1 TI'~OUGH 4 <br /> lob Desc~ ~tion <br /> <br />R~si&ntlalx New( ) Replacement( ) - ~' ~ ~ 'R3arage or ~arpoa <br /> ( )Attached <br />Comraemlal( ) New( ) Replacement( ) ( ) De~ached <br /> <br />Manu~acturelas Yeag of [ Color of ] W~dth: <br /> <br />2, Location of Installation ~ fi;> <br /> <br />Subdlviaion ~t ~ ~l~k Urba~ Growth ~ounda~7 <br />Mobg~HomePa~ 8~ .... Y( )N( ) <br /> <br />Sectim Towns~p ~nge ~* Map Wa~r Supply: <br /> Privam Well ( ) Sprig <br />I,~ Wid~ I~ ~h Arms ~g, I~t Comer C~nmunit7 Well ( ) City <br /> <br />3, Contractor Information <br /> <br />( ) I w[~ be my own g~eral'~nt rata on <br /> <br />immediamly noOfy Marion County of the name of the contractor. <br /> <br /> Contractor Buslneaa Name & #: I Mail~g Address: [ Phone: <br /> ( ) I am a registered bu lder OR the aatho~e~d representative of a registered builder. <br /> <br />i,Aolhotized agent or lea~ee: tMdfllngAddms$: t Phone: <br /> 4. Fee Schedule <br /> <br />A. (1) Manufacturexl Home <br />or Modular Unit Placem~lt/Ccnmectlon @ $182,00=__ <br />(2) State I*~ @ .20.00 =__ <br /> @ 9-I0=__ <br />O) SI~le Sureha,ge @ 15.00 = ~ <br />(4) Zoning Surcharge (15.00 if applicable) <br /> <br />(I) Mfg.'d Stmclum Storage Fee <br /> <br />(2) Mfg.'d Structure Storage Renewal <br /> <br />(3) Zoning Surcharge (1;~,OOifapplicable) <br /> <br />C. Additional IilSl>eCfion ~ $60.00 <br /> or Rchu~pectk,~ <br /> <br />D. Investigation Fee <br /> <br /> TOTAL $__ E. Olhct JJIspecticma not l~ted ~!~ $40.00 -: .... <br /> <br />@ 25.00 =__ TOTAL= $ <br />@ m00 = ~L~_.&v?-- <br /> RECEIPT: <br /> <br />I hereby ceWl'y that the above in~onnalion Ja ~cct ~d ~at I ~ve mad and understand ~e ~fo~alj¢~ Not{ce to Pr~e~y Owners about Cm~truction Responsib~es <br /> <br /> <br />