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MARION COUNTY BUiLDII~I INSPECTION <br />:FOR OFFIcE]UsE ON~YI 2:20 High Street I~)~f~ ~-~EQR OFFICE USE ONLY <br />Received by:~ Salem OR 973~1~ I ~.~ ~'~'~/,~ ~,~k Requ~remeni;: <br /> <br /> MANUFACTUREDSTRUCT~E P~M~ ~ <br /> , P~R~T APPLICAT O~a~lON O , , '~' '~" .... <br /> CO~LEfgALLSEC~ONS, IT~OUGH4 ~l~)t~.. OU ~ ~,(~. ~) ,.. Y'.(~ ,.2 <br /> m ut 8 INS ,o <br /> <br />2. Location of Installation ~t~Jta///~. ~ ~- q'~q-- <br /> <br /> ,,~~, ~ q7g~ simNo, ,,. <br />Subdlvifim ~ ~BI~ Urban Growth gounda~? <br /> <br /> ) ) .... <br /> <br /> ............... P~vam Well ( ) Spmg <br />~gWid~ ~';' I~De~ ~ t Aem~ I~8-~ Comer fig Commu~tyWen( ) City <br /> <br />3. Contractor Information <br />P~op~ny Ow~ ~ <br /> <br />1 Mailing Address ,IPh°ne No. <br /> <br />( ) i own, reside in, or will reside in [he completed structure, <br /> <br />( ) I will be my own geaaeral eontracton <br /> <br />Aughori~ed agent or Ieasee:~ <br /> <br />4. Fee Schedule <br /> <br />77~' <br /> <br />A, (1) Manufactured Home <br /> or Mo&fiat Unit l'lacement/Cotmectio~ <br /> <br /> (2) State Fee <br /> <br /> (3) State 8urcha~e <br /> <br />B, (1) Mfg,'d Structure Storage Fee <br /> ¢) ~g,'d Stmemm S~rage Renew~ <br /> <br /> (3) ~ng Sufc~e (15.~ if app~eable) <br /> <br />I hereby Certify ghat the above information is cermet alld that I have read and undemmnd ~c ~fomatim Notice to ~eRy Owne~ about C~struction Respmsib~fies <br />on ~e revere side of ~is fern, <br />N.meofA~llcant~i~~ Phone: 7~,--~fl~~./ <br /> <br />This fee c~crs ~c manufactured ~tmctum platinol, plumb~g ~nnecfi~, dectfic~ come.on ~d mechanical connectinn. Site evaluation, attptic pe~ti, electrical <br />~e~ic¢ or pl0mbing water/sewer lines am serrate ~uimd ~it~, MC 15-64 Rev 11-91 <br /> <br /> <br />