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' MARION COUNTY BUILDI[~II~ 12N8.1~. C,~TID~N. ~, ~ <br />FOR <br />Received by:~' Salem, OR 973~ ~ ] ci~ ~k <br />ZomngValidafio~ ~ 8:~-4:3~588-5147 ~ 0 ~ I~ /~ .......... ] <br /> ~t~ t Rear: <br />Da~: ~/a~/q~ ......... ~e-A-mm~p~ 588-7948588-79~ [L~tS[de: fl~ t lmm, Side: <br /> <br />Residential( 1~ N~(~'"~~' Replacement( ) Garage or Carport <br />Commcrclal( ) N~( ) Rep~( ) ( ) Attuned <br /> ...... ( ) Deta~d <br /> <br />2, Location of Installation <br /> <br />3. Contractor Information <br /> <br /> ) I om, reside ~, ~ wffi m~ide M ~e e~ple~d <br /> <br /> ) I unders~nd ~at I muat m~s~r as a cmstmafim mn~etor ff ~e s~m is sold or offe~ for sale befo~ or <br /> <br /> ) I wi~ b* my o~ g~eral cent ~. <br /> <br />If I him aubconWactor~. I will Mm only subcontractors registered with the ConstmcEon Cmtractors Boa~. <br /> <br />lC I change my mind and do him a general contractor, I w~ll contract with a ce~traotor who is registered with the Construction Contractor's Board, and will <br />immedlamly notify Marion County of the name of the contractor, <br /> <br />( '~')"I'~am a rogiste~d boilder OR the authorized representative ufa registered builder. ~j~, ~$~/.~//~,. ~f~ <br /> <br />4. Fee Schedule <br />^, (1) ManufaCtured Home <br /> or Modular Unit Placem~nffConne~on @ <br /> <br /> (3~ State Su~ha~e <br /> <br /> J <br /> <br /> ~TAL: <br />B, (I) Mfg,'d St~¢tu~ S[orag~ Fc~ <br /> ~ $ 25.~ = <br /> (2) ~g.'d Structure Sm~ge R~ewM <br /> <br /> (3) ~mng Sumhage (15.~ <br /> <br />C. Additional Insp~tion @ $60,00 <br /> or Reinspeet/on <br /> <br />D. Inves~ga6on Fee <br /> <br />E. Other thspe~ti~s not listed <br /> @ 40,00 per hour (2 hoar minlmum) <br /> <br /> @ $40.0O =-__ <br /> <br /> TOTAL-~ <br /> <br />RECEIPT: <br /> <br />Signature of ~-.~.t.---r.~-.¢_~ ~t..~ /2~'J-~.~-.a-.'- Date: ~.7~-~'~'~- <br />MC 15-64 Rev 11-91 <br /> <br /> <br />