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220 High Street NE <br /> Salem, OR 97301 <br />g:00 am-4:30pm Phon~ 588-5147 <br />Code-A-Phc.~e 588-7904 <br /> FAX 588-7948 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> FOR OFFICE USE ONLY <br /> I City Setback Requir~rnenls; ; <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLETE ALL SECIIONS. 1 THROUGH 4 <br /> <br />2. Location oflnsmllafion <br /> <br />Job Address 511 <br />Sub,vision ~t I Bl~k Urban Growth Bounda~? <br /> <br />Set,on TownsMp Range Z~e Map ' Water Su~ly: <br /> ................................................ PfivateW~ ( ) Sp~g ( ) <br /> <br />3. Contractor Information <br /> <br />]Phone No, ~'~' ,- ~:~.2_~_ 7 <br /> <br />(~) i resid* Jrt, will ~slde ~n the completed structure, <br /> <br />( ) I will be my O~ general comra~tot <br /> <br /> If ! him subcontractors, 1 ~ hke only subcontractors registered wi~ the Construction Contractors B~. <br /> <br /> ~ I ch~ge my ~d and ~o Mm a g~e~ ~mc~r, I ~ ~tmct wi~ a ~aemr who is m~smmd wi~ ~e Cons~cfion ~ntractor's gourd, and will <br /> fimedjam[y n'o~y Mad~ County of thc namv of ~e ~ntr~r. <br /> C~t~cmr Bus~ess Name & ~: ~ Ma~g Address: <br />2~) I am a mgiamrod budder OR ~c au~od~d ~s~n~ve ora ~gis~ b~d~. <br /> <br />4. Fe~ Schedule <br />A. (1) Manufactured Home <br /> <br /> (2) State F~ <br /> <br /> (3) State Su~ha~e <br /> <br /> (4) ~ng Surcba~e (15.~ if a~llcablc) <br /> <br />B, (1) Mfg,'d Structure Storage Fee <br /> @ $ 25.00--__ <br />(2) Mfg,'d Stmemm Storage Renewal @ 25.1)0 ;__ <br />(3) Zoning Sumbatge (15,00 if applieabl~) @ 15,00 ~__ <br /> <br />C, Additional Impe~tlon <br /> or Reinspeetion <br /> <br />D, ~vest~gafion Fee <br /> <br />E- Other i~slx:¢tleas n?listea <br /> @ 40.00 per hour (2 hour minimum) <br /> <br />@ $60.00 =__ <br /> <br /> @ $40,00 <br /> <br /> TOTAL= <br /> <br />RECEIPT: <br /> <br />Name of App~cant ~lea:e p~t): " ' > ,Phon~: ~Y'- Y2 ZT <br />Signat~mofAppHcant: Date: ~C~ ~ /~ <br /> <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />