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MARION COUNTY BUILDING INSPECTION <br />· FOR OFFICE USE 220 High Stxeet NE FOR OFFICE USE ONLY <br /> Re~ived by:~7~E-~ Salem, OR 97301 I~ <br /> Z om ng Valid?~t i~- ~_~-~L~ [ 8:~ am-4:3~ ~me 588-5147 ]Fret: [~ ]Rear: <br /> ~-A-~ 588-7904 ]'~ Sia~; ~ lm~ Sia~; / <br /> MANUFACT~ED STRUCTURE PLACEMENT <br /> CO~L~E ALL SEC~ONS. 1 T~OUGH 4 PER~T APPLICATION <br /> 1. Job ~hphon <br /> <br />2. Location of Installation :, <br /> <br />Job^~d~ 910 gc~Or~q i)r'. T~A~No. . ..... Cro~St,~e~lfi;tlFz, eel(' <br /> <br />Subdi~m ~ :' '." Bilk U~an G~wth goanda~? <br /> <br /> ............. ....... CmmumtTwe~[,( ) C~ty <br /> <br /> 3. Conzactor information <br /> <br /> ~) I o~, ~Me in. or ~ ~side ~ ~ eom~ed stm~ <br /> ( ) I ~de~mnd ~at ~ must g~smt as a c~st~fi~ o~ ff ~e s~m is sold ~ offe~ for s~ before or u~ cmpledon, <br /> <br /> () I wffi b~ my om gmeral cm:m~or. ::, <br /> <br /> ~ i him sub~ctom, I wffi ~ o~y m~ntm~m mgist~ wi~ ~a C~s~on Cmtraemm Bmr& <br /> <br /> ~ I ~ge my mind and do ~m a g~er~ ~nmc~r. I ~ ~et ~ a ~r w~ ~ m~s~md wl~ ~e C~s~e~ Contmctots Bead, and wi~ <br /> im~ly no~y Ma~ ~W of the n~e of ~* <br /> <br /> (~) I am a mgis~md b~dcr OR ~ au~fi~d m~s~u~v, of a mgismmd b~de[ <br /> <br /> 1-- <br />~'4. Fee Sch~ule .' · :: <br /> <br /> A. (1) ~nufa~umd <br /> B, (1) ~g,'dStmcmmS~mgeF~ ~ 40.~rhour(2h~r~m) <br /> <br /> I hereby certify that the above information is correct and that I haY6 read and tm3erstand the ]hformation Notice to ?roperty Owt~¢rs about Conztmctjo~l Responsibilities <br /> <br />Signamn~o£Apvlicant, 5~~' Date' ~}ff-ff'.-"'~'~--. 1~[~ % , <br />~Thls fee covers the manufa¢lul~d stn~ture placement, plumbing connection ~lectrical connect on 0zld mechan ca comlection. Site evaluation, scpli¢ permit, electrical <br />service or pllltlth{rlg water/rower Iine~ are separate requlmd permim <br /> MC 15-64 (er -9 <br /> <br /> <br />