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MARION COUNTY BUILDING INSPECTION <br />220 High Street NE FOR OFFICE USE ONLY.I <br />Salem, OR 97301 city Setback Requirements: <br /> 8:00~rl-n:30praPhone588-51q'? Front: //, R, r, ' / <br /> Code-A-Phola~ 588-7904 <br /> <br /> MANUFACTURED STRUCTUR~,~E PLACEMEI~M PERMIT APPLICA1 ION <br /> <br />COMPLETE ALL SECTIONS, <br />1. Job Descri ~tion <br /> <br />2. Location of Ini!811ntion <br /> <br /> 3. Contractor Information <br /> <br />~) I own, ~slde M. ~11 reside M the ~ple~d s~um. <br /> <br /> ( ) I w~ ba ~y o~ gmc~ emtm~, <br /> <br /> If I him subcontractors. I wil[ him only subcontmctor~ mgis~e, ted with ~o ~nstmai~ Cm~acto~ B~rg. <br /> ~ I chmga my ~d and do bi~ a gener~ mntramor~ I ~ ~ntmct ~ a cmuacmr who i~ m~s~d wi~ ~e Con,tracOn Con/rector s <br /> ~dia~ly no~y Ma~n Co~ty of ~e n~ of ~ o~actm. <br /> <br />~umori~ agent or leasee:~''~' IM~g Address: ~[.~ ~i~ ~e~ [ Phone', <br /> 4. Fee Schedule ~.) ,,. , <br /> <br />A. (1) Manufactured Home <br /> or Modular Unit PhcementfConncetlon <br /> <br />(2) Stato F~ ' <br />(3) Stat~ Surcharge <br /> <br />(4) 2onhag Surcharge (15.00 if applicable) <br /> <br />B. (1) Mfg,'d Structure Storage Fee <br /> @ $ 25.oo .~.__ <br />(2) Mfg.'d Stmem~ Storage Renewal @ 25,00 = <br />(3) Zoning Surcharge (15.00 if applicabl~) @ 15.00 =,__ <br /> <br />C. Additional I~speefion <br /> or ReAnspeet~on <br /> <br />D. Investigation Fee <br /> <br />g. Other inspections not listed <br /> @ 40,00 per hoar (2 hour mlrdmum) <br /> <br />$60.0o= <br /> <br /> @ $40.0o <br /> <br /> TOTAL -- <br /> <br />RECEIPT: <br /> <br />I hereby certify that the above information is comet and that I have read and understand the luformatJon Not, ce to Property Owners about Constroction Respo~lsib~tics <br />on the reverse skle of this form. <br /> <br />Th/s l'e~ covers lh¢ ~ila~Jfaeturcd structu~ p}acemenl, plumbi~§ o2qln~¢tion, al ectrleal connection lmll mechaulcal ¢or~¢c00fl. Site eva]uatton, ~epti¢ permit, elec£tical <br />service or plumbing waler/sewet linei are'~z~arate required permits, MC 15 -64 Rev 11-9 <br /> <br /> <br />