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MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NI~ · n~,,= .... .IFOR OFFICE USE ONLY[ <br /> Salem, OR 97301 ~[i.;,HV~;~ ~¢ity s.~,¢k,~,,~: I <br /> C~e-A-~one 588-7904 [ ', <br /> <br />MANUFACTURED STRUCTURE PLACEMENT PER~T APPLICATION ~R[0~ <br /> <br />COMPLI~'I'E ALL SECTIONS. 1 TI-IROUGI 1 4 <br /> <br />2. Location of Installation <br /> <br /> C. nei ' d"""ffb4 Dr, iq <br /> Job Add · ,.r~x ACCL No. <br />_ ~u.~.~o~ [te~ 0¢, q~ 3.~.~ ......... s~,~No. <br />SubdMs~ ................. L~ Igx Urban Growth Boundaw? <br /> <br /> $ecd0n ] To~s~p Range Zme Map Wa~t 8a~ly: <br /> PfivateWeti ( ) Spring <br /> ~h~iX~-"D~..~ ......... ........ LaDe~h q3' A~ ~,.~ Comer Commudt~WOl< ) City <br /> <br />3. Contractor Information <br /> <br />()q) I own. ~side ~, or w~ ~side ~ ~e c~ete~ stm~u~. <br />( ) I unde~mnd ~a[ I taus[ ~$smc as a ¢ons~efi~ ¢~acmr ff ~e s~n~ ~ sold ~ offe~ for s~e before or z~n c~tplefioa. <br /> <br />( ) I wi~ ~ my o~ g~ec~ e~tra~, <br /> <br />1~, I change my mind and do him a general contractor, I will contract with a contractor who is registered with the Construction Contractor s Boa d, and Will <br />i~mnediat~ly notify Marion County of the name of the Contractor. <br /> <br />( y)I ama rcglstc~8 builde~ the au thodzcd ~pms cntativc ora registered builder. <br /> <br />4, Fee $ched01¢ <br /> <br />(1) Manufactured Home <br />or Modular Unit Placement/C~mnect{on @ $152.00 =/fo7 ~ <br />(2) Stat~ Fee @ 20'00 = ~' ~ <br /> '@ 9,10-- ¢~~ <br />(3) State Sumhatge @ 15,00 = ' <br />(4) ~aming Surcharge (15,00 if applicable) ~ ~ <br /> <br />B. (I) Mfg,'d Structure Storage Fcc <br /> @ $ 25.00 =__ <br />(2) Mfg,'d Structure Storage Renewal @ 25.00 =__ <br />{3) Zoning Surcharge (15,00 if applicable) @ 15.00 -- __ <br /> <br />C, Additional inspection <br /> or Reinspection <br /> <br />D. Invesfgafion Fee <br /> <br />E. Other inspections not listed <br /> @ 40.00 per hour (2 hour minimum) <br /> <br />@ $60.00 ::__ <br /> <br />$40.00 = <br /> <br />on the reverse side-of this form. <br />sc~ice or plumbing water/sewer line~ am separate ~uimd pe~it~. MC 15-64 Rev 11-91 <br /> <br /> <br />