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[ FOab FIC u sgpE I <br />R~ce. ived by~l <br /> Zoning ¥?idation' ~O.7~-~t/ / <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br /> PER~T APPLICATION <br /> CO~LETE ALL S EC'I~ONS, 1 THROUGH 4 <br /> <br />MARION COUNTY BUILDING INSPECTION <br />220 High Slxeet NE I FOR OFFICE USE ONLYI <br /> Salem, OR 97301 I ¢.ity Setback Requlreme.ts: [ <br /> 8:00 am.4:30pm phone 5811-5147 <br /> Code-A-Phone 588-7904 <br /> FA× 58a-7948 [ Left S'ut~ Iuash~ia~: <br /> <br />1. Job Description <br /> <br /> ( ) Attached <br />Commercial( ) New( ) Replacement( ) ( ) Detached <br /> <br />2, Location of Installation <br /> <br />......... ' ............... Maltin. Aadress <br />Job ~a~. <br />- ,.:: z I Bl~k Urban Orow, h BoundaW? <br /> Subd~vmon ~ ~ ~e ~ ~ Lot <br /> MobfleI-ImePa~ ~ce~ Y( )N( ) <br /> ~ Pfiva~W~ ( ) Sprig ( ) <br /> <br /> Contractor Information ~ ~ <br /> ) I un~rsmO ~at I must rc~st¢r as a c~st~fi~ ¢ontmct~ g ~C sternum ~ soM or ~e~ for sale before o; u ' <br /> <br />imm~hmly .o~y Marion Comty of the nam~ of m, c~n ~ ~,z~ ,t vovkOTtON <br /> ) [ am a regis~md'bufldcr OR ~ aumori~d mpmsenmfiw of a mgiste~d b~der, r <br /> <br />Authorized agent or l~asce: <br /> <br />Maili~g Addmsg: [ Phone; <br /> <br />4. Fee Schedule : ........... <br /> <br />A, (1) Manufactured llome <br /> <br /> or Modular Unit Placeanem/Comlection @ $I82.00= <br /> <br /> (2) State Fe~ @ 20,~ ~ <br /> ~ 930: <br /> <br /> (4) ~ ~.~d~a~ (1 ~¢ ik <br /> <br />B, (1) Mfg.'d$t~cm~S~rageFee <br />(2) ~g.'d 8[mcm~ Swage Renew~ ~ ~,~ = <br />(3) ~ng S~mha~e (15.~ if app~cable) ~ 1 ~.~ = <br /> <br />C. Additional Inspection <br /> or Relnspection <br /> <br />D. Investigation Fee <br /> <br />E, O~h~insp~ctions notllsted <br /> @ 40.00 per hour (2 hour nfmimum) <br /> <br />@ $60.00=__ <br /> <br /> ~_~ $40.00= <br /> <br /> TOTAL= $___ <br />RECEIPT: C~f~, ot~5~ <br /> <br />I hereby ¢egclfy that the above information is correct and that I have read and under~tand the Information Notice to Properly Owners about Construction Respon aibilitie~ <br />on the reverse side of this form, <br />NameofApplicant(pleasoprint);,~?7.~,~ /t ~t~-~"l[/{'" Phone: ~/~ ~01~ ~'~-~J <br /> of Applicant: _ff~ '~ ~~ Dam'. ~ '~-~ / -- ~} ~¢~ <br />$1gnatum <br /> <br />service or plumbing watedsewer lines are separate required permits MC 15-64 Rev 11.91 <br /> <br /> <br />