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MARION COUNTY BUILDING <br />[FOR OFFIC~ ~$EzONLYI 220 High Street NE ~lVE~OR OFFICE USE ONLY <br />/Received by: ,~/, ~/ ~,~z~-- [ Salem, OR 97301 <br />/Zoning Validat~on'f~---u/fi'~/ [ 8:00 am-4:3Opm Phone 588-5147 BO <br /> <br /> FAx 588_7948 <br /> MANUFACTURED STRUCTURU <br /> COMPLETE ALI. SEC~ONS, 1 W~OUGH 4 PER~ APPLICATI~}J_OI~O <br /> 1, Job D~ripfion ~ O 0 ~ J ~ <br /> <br />Commercial( ) New( ) Replacement( <br /> <br />2. Location of Installation <br /> <br />SuMivis~ ~ I Bl~k Urban Gwwth Bounda~? <br /> <br />Scrim Towns~p Range Zme Map Water Su~l),: <br /> PfivamWell ( ) Spring <br /> <br />Contractor Information <br /> <br />Lf I hire subcolaraetors. I will hire only subeontraclora registered with the Construction C~mtraetors Board. <br /> <br />If I change my m/nd and do hlre a general contractor, I will contract with a contractor who is registered with the Construction Contracto?~ Board, and will <br />immodlately notify Marion CoUnty of the name of the ,ontractor, <br /> I m au gAdth =s' t37 ' i ¢.l lPh° e:7 q'?Tqq <br />Z) I am a registered builder OR the authorized representative of a registered builder. <br /> <br /> orlzed agem or lessee: ][ Malqn Ad&ess' <br /> <br />4. Fee Schedule ; <br /> <br />A. (I) ManufacturedHom~ <br /> or Modular Unit Pla ce,ment/Conncctlon <br /> <br /> {2) SLate Fee <br /> <br /> (3) $~ate Surcharge <br /> <br /> (4) Zoning Surcha~e (15.00 if appIieable) <br /> <br />B. (I) Mfg.'d Structure Storage Fee <br /> (2) Mfg.'d Structure Storage Renewal <br /> <br /> O) Zoning Surcharge (15,00 if applioabl*) <br /> <br />15182.00: / °~ <br /> 20,00-- ,~ -~,~a C. Additional Inspection <br /> or Rdna~efion <br /> 9,10;~ <br /> I~.~; D, ~vesfigati~ Fee <br /> <br /> ~TAL: $ ~ ~a E, ~er ~s~e~ons not <br /> ~ ~.~ ~r hour (2 hmr minimum) <br /> <br />$60.00 = ,-- <br /> <br />@ $40.00 <br /> <br />TOTAL: <br /> <br />on the reverse side of this form. <br /> <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />