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FOR OFFICE USE ONLY/ <br />Received by:-- <br />Zoning Validation: <br />Date: <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> g:~O am-4:30pra Phone 588-5147 <br /> Codc-A-Phon~ 588-7904 <br /> FAX 5gg-794g <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLETE ALL SECTIONS. l THROUGH 4 <br /> <br />I. Job Description <br /> <br /> FOR OFFICE USE _ONLY <br />/ C!ty,,~tb~ek Requircnnents: <br /> <br />Commercial( ) New( ) Replaeemmt( ) ( ) Detaehett <br /> <br />Ser , Ma.u£ae re= A ove¢ ....... ' <br />Type of 7[d,~,~ ~, of Ro~mg: I Sq. Fmtage; INc. B6dmm~: <br /> I <br /> <br />2. Location of Installation <br /> <br />PropertyOwner'R-& El. Wil'ii'a~tsoe""[~'~'~g^ad~s~ ~"~527 Case Rd. Aurora,O~honeNo,678-5585 <br />J°bAddms~19687 Case rd. Aurora, OR 97002T=Aeet'N°/~.-41835-000 C~°ss$~reetS~c. Paul Hit <br />Site No. <br /> <br />Mobile Home park Sp,aee # Y( ) N( ) <br /> Pfivatc We[I ( ) Spring ( ) <br />LotWldth LotDepth Aeres~(,~2~ Irreg, Lot Comer CoramunltyWe11( ) City ( } <br /> <br />Y <br /> <br />3, Contractor Information <br />Pr°pertyOw"erR & E. Williamson IMamngAda~esaurora, OR 97002 IPh°"eN°'678-5588 <br />( ) I o~. reside m. ~ wiU ~side ~ the eomple~ s[mau~. <br /> <br />( ) I wi~ be my own gmeral c~[naon <br /> <br />immediately notify Marion County of the name of tho contractor. <br />Contractor Business Name & #: I Mailing Address: I Phone: <br />( ) I am a reglstemd builder OR thc authorized rep~sentafive of a registered builder. <br /> <br />Authorized agent or leasco: [Mailing Address: Phone: <br />4. Fee Schedule <br /> <br />A. (I) IVhnufaetomd Home <br />or Mothdar Unit Placemtmt/Cceaneetlon @ $182,00 ~__ <br />(2) State }~ee @ 20.00 = <br /> @ 9,10 = <br />(3) State Sorcharge @ 15.00= <br />(4) Zoning Surcharge (15,00 if applicable) <br /> TOTAL: ~t <br /> <br />g. (1) M£g.'dStmctureStotageFee <br /> @ $ 25,00-- <br />(2) Mfg,'g Structure Storage Renewal @ 25,00 =- <br />(3) Zoning Surcharge (15,00 if appl~¢abl~) @ 15,00; <br /> <br />C, Addifionallnapeeaon @ $60.00=__ <br /> or Reinspee~ion <br /> <br />D. ImvesligaTion Fee <br /> <br />1~, Othexinsl~ctions not li~ted @ $40,00 = __ <br /> @ 40.00 per hour (2 hour minimum) <br /> <br />TOTAL = $__ <br /> <br />I hereby certify that the above information is correct and that I have read and understand the Information Notice to Property Owners aborn L'~h'gff0 erich Responsibilities <br />on the reverse ~ide of thi~ form, <br /> <br />SignatumofApplicant: ~< tI ] ~ ~'/ V'"~/~r~/Ld Date: ~ _ Lp __,,...,,,7~ <br />This fee cover~ the manufactured ,~tmetut¢ placetB¢llt, pl~mb~g {0n~ec~. ~t~c~ comec~on md mechanical connection. Site evaluagon. ~cptlc pe~nlL elecldcal <br />semiee et plumbing waft/sewer ~es am separate ~uiM pe~its, MC 15-64 Rev 11-91 <br /> <br /> <br />