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IFOR OFFIC~ USlg ~NLY <br />Received <br />Zoning Validation: <br /> Date: · ~ ''~- <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, OR 97301 <br /> 8:00 am~i;30pm Phone 558-5147 <br /> Code-A-Phone 588-7904 <br /> FAX 588-7948 <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br />COMPLI~TE ALL SECTIONS, l THROUGH 4 PERMIT APPLICATIO..~'~ <br />1. Job Description ~-~ ~9 ~)~ t~ <br /> <br />FOR OFFICE USE ONLY <br /> <br />Commercial( ) New( ) Repheem~nt( ) (~ <br /> <br />Serial #: ~. t{ 5 aX[ ~ Manufacture: q ,,, AppleS ~1: Ce..&, ~{ <br />Ty~ofSi*ng; ~OOd ........... ~,ofR~fing: CO~p, ]$q',~,~,C~e: ]qOq {No. Bedrooms; D <br /> <br />2. Location of Installation <br /> <br />Subdivision ..... Lot IBlock Urban Growth Boundary? <br /> <br />Section Township Range Zone Map Water Supply: <br /> ................. PdvateWell ( ) Spring ( ) <br /> <br />3, Contractor Information <br /> <br />(~) I o~, msid~ M, or ~ ~side M t~ ~mple~d s~u~. <br /> <br />( ) I ~ be my own gmet~ <br /> <br />If I him subcontractor% ! will hike only subeo~tra¢to~ registered with the Comtmction Ccatractoi~ Board. <br /> <br />If I change my nfind anti do him a general contxa¢tor, I will contract with a ¢ffatractor who is registered with the Construction Contraetoes Boa rd, and will <br />~Jnmed~ately not~fy Marion County of the name of the contractor. <br /> <br />(~) I am a regi$tei~d builder OR the authorized representative of a mgiste~ti builder. <br /> <br />4. Fee Schedule <br /> <br />A. (1) Manufactured Home <br />or Mod slur Unit PheegntmtlCtame~tion @ $182,00= <br /> <br /> C2) State Fee @ 20-00 -- <br /> @ 9.10 = <br /> (~) State gurcharge @ 15.00 -- <br /> (4) Zoalng Surcharge (I5,00 if applicable) ~ og <br /> TOTAL; <br /> <br />B, (1) Mfg.*d Structure Storage <br /> @ $ 25.00 =__ <br /> (2) Mfg.'d Structure Storage Renewal <br /> <br /> (~) Zoning Surcharge (l 5.00 if appJJ~able) @ 15.00 -~__ <br /> <br />C. Additional Inspection @ $60.00 := __ <br /> or Reinspeclion <br /> <br />D. Investigation Fee <br /> <br />@ 40.00 per h~ur (2 hour minlmum) <br /> <br />¢t~ $40.00 = . <br /> <br />I herchy certify that the above information is cermet and that I have mad and understand the Information Notice to Proper~y Owner~ about Conxtruction Re~pon~Jbilhies <br />on the mver~e sidle of this form. <br />Name of Applicant (please print):~ ~'~(~ la' Dr- tX C~_.5' <br /> /\ <br />service or plumbing water/sewer lines a~e .~r~'~C~te required permits. <br />This fee coven the manufactured stmctu pla ' 'mem. plumbing connection, electrical connection and mechanical cotmection. Site evaluation, scptic permit, electrical <br /> <br /> MC 15-64 Rev 1]-9I <br /> <br /> <br />