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MARION COUNTY BUILDING INSPECTION <br />'~FoR~oFFIC4g USE O~LYI ~ 220High StreetN~ Fg'x r~-. }FOR OFFICE USE ONL~ <br />Received by: ~ ~J ~ /., ,..~ ......... S~om, OR 97301 IP~]~ ~~~ --~ <br /> Zoning Valifia~0~ ~' ] ~/' s,~ amM'3 ~ 5SS'51 ' R~ar e <br /> Date: /~ ~ ~ [ ~-~-~ ~sS.79~ , ~ - ~ <br /> <br /> MANUFACTURED STRUCTURE PLAC~ ~ <br /> ~TE ALL SEC~ONS, 1 THROUGH g PER~T APPLICATION ~ ~ ~ ~ 0 ~ <br /> <br />2. Location of: iff <br /> <br />Su~visi~ Lm ] Bl~k Urban Growth Bounda~? <br /> <br />Se~,ion ,~4 To~s~p ~5 ~ng¢ ~ ~ ~ Map WaterMu~ly: <br /> PfivamWe~ ( ) Sp~g ( ) <br /> <br />Contractor Information <br />Property Owner'S/ ~,.~.~F.~-, I Mailing Address ]Phone No. <br />) I own. reside in. or will reside in the completed stTucture. <br /> <br /> ) I will be my OWn g~lettd contractor. <br /> <br /> change my mind and do hire a general contraOx>r, I will contract ~ a c~c~r who is m~stemd ~ ~e Constmc~on Contractor's BoaM, and wiR <br />~led~mly no~y Marion CounW of the nam~ of ~e ~n~r. <br />Contmcmr,usincssNamc&~:.. ~~ ~s~glMa~gAdd~ss: ~ ~ <br /> ~am a ~gis~ builder OR ~e au~ofi~d m~s~mfive of a ~gis~ ~d~. <br /> <br />4. Fee $chodOle :." <br /> <br />A, (1) Manutactmed Home : " '" ' <br /> <br /> orModularUnitplaeement/~onneetlon @ $I$2,00~ at~sa~, W10 C, Add. Mor~alL~speet~on ~3 $60.00=__ <br /> <br /> (2) Stat~Fcc @ 20.00= ~q¢;!~ ~eReinspcctlon <br /> , @ 9ao;~ 0 <br /> <br />B. (I) ~g,'d Stmctum S~mge F~ ~ 40.~ ~r hour (~ h~r minimum) <br /> ~ $ 25.~ ;~ <br />~) ~g.'dg~cmmSto~e~cw~ ~ 25.~:__ TOTAL= $ <br />O) ~ng Surcha~e (15,~ if applicable) ~ 15,~ ~__ <br /> RECEI~: <br /> <br />I hereby certify that the above infoanalion is oarmet and that I have r~ad'and und~r3tand the InformaTion Notice to Froperty Owners about Ccrns{~action RespOn sibilitie~ <br />on th~ reverse side of this form, <br />N ,ofApqlicant(p~_~y~~'~0 Phone: 7~57-77t'~_~5 <br />Signl,m-atumofApplican[: fi' ~-'-v~.~ ~-~-~ ."~--~.~.~ Date:, t~--~:~ <br /> <br />service or plumbing water/sewer Lines are separate required permits MC 15-64 Rev 11-91 <br /> <br /> <br />