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r o R:OF .I . 220mgn <br />[Reeelved 5~.~ ] ,p~ Salem, OR 97301 <br /> <br /> MANUFACTURED STRUCTURE PLACE~T <br /> CO~LETE ALL SECTIONS. 1 THROUGH 4 PER~T APPLICATION <br /> <br />2. Location oflnstallaQon ,,, /ff~t~,f~//~ ffff, :~ q7J~TS- <br /> <br /> ~so~/le, ~',,,',~ .... si,~ ~o,, "" <br /> <br />Sub~iv~i~,, , Lot ............ J Bl~k Urban Growth <br /> <br />LotWid~ ~g L~Dep~ ~g Acm* ...... ~g~t ~0 Comer ~ PnvateWcI[ ( ) Spmg( ) <br /> ........................... 9ommunity Weg ( <br /> <br />3. Contractor Information <br />"Pmper~yO~ner ~t~f~Oq..ff~ ~'""~'1~,'} [MaflmgAddre~s [PhoneNo <br />( ) I own, reszde m, or wzll mslde Jn the complete~] ~tmctum. <br /> <br /> ( ) I wilt be my own g~meraI cOntractor <br /> <br />mlmediately notify Marion County of the name of tile contractor. <br />CsP?~ct°tBusmesaName&#:~e~.~$[4*'~d~-~) ~qVO [MarimgAddress~ ~ d~ Phone <br />( ~'~am a registered builder OR ~e au~ofir~d m~s~[afive ~ a mg~m~ bMld~v, <br /> <br />4. Fee Schedule <br /> <br />A.. (1) Manufactured Home <br /> or Modular Umt I%cement/Cc~necQon <br /> <br /> (2) State <br /> <br /> (3) State Sumharge , <br /> <br /> (~) ~fi.g Su,~i,arge (i~&5 ii appl~¢a~R0' <br /> <br />PJ (I) Mfg'd Structure Storage Fee <br /> @ $ 25,00 = <br /> (2) Mfg d Structure Storage Renewal @ 25.00 <br /> (.) Zomng Surcharge (15.00 if appheable) @ 1500 <br /> <br />C Additional Inspectic~ @ $60 00 = <br /> or Re.b*spe¢fon <br /> <br />D. Investigaiion Fee <br /> <br />@ 4000 per hour (2 honr mimmom) <br /> <br />Q~ $4o fi)=__ <br /> <br />TOTAL= $ ~/g ff'O <br /> <br /> <br />