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MARIOI~ COUNTY BUILDING IN~TION <br />, F~R oFF~LY, J ~20 High St,ce, NE /f(~-~(~~O~F~FIF E US E ONLY <br /> Re ceived b y~ c'~.~r..~ ~)x~Dt---~.~ Salem, OR 97301 aJ~~' ~ ~~[emmt,.. .J <br /> <br /> COMPLETE ALL SEC'HONS, 1 THROUGH 4 <br /> <br />2. Location of Installation <br /> <br />3. Contractor Information <br /> <br />( ) I o~, msMc M, ~ w~ msid~ M t~ c~plcmd <br /> <br />( ) I un.mind ~at I must m~s~r aa a ~stmcfi~ c~r ff ~e s~m is s~ ~ off~d for s~* b~om or u~n cmp~fim, <br /> <br />L/I hL~ subcontractors. I will h/m only ,ubcontractora mgiat~'ed wi~ ~e C~s~ion C~mm Bmr& <br /> <br />~ 1 *b~ge my m~d and do ~ a g~ml ~e~r, I ~ ~act ~ a c~ae~ w~ b ~stemd ~ ~c Cons~cfi~ C~tra~of s Board, and wi~ <br /> <br />( ~I am a rcgis~md budder OK ~ ~o~d m~*mmfive ~;a ~gi~t~ ~. <br /> <br />4. Fee Schedule <br />A, (1) Mantdactumd Home <br /> or Modular Unk PlacemcnqConneoJon <br /> <br />C, Addit/onalinapecfion @ $60.(X) = <br /> or Keinspeefion <br /> <br />D. lhvcsfiga6on Fee <br /> <br />E. Other insl~ions not t/md <br /> @ 40,00 ~er hour (2 hour midmum) <br /> <br /> @ $40.00 ~____ <br /> <br />TOT^L~ $.~Z.3~. OdD <br />RECEIPT: ~ <br /> <br />i hat, by certify that thc above in/ormation is correct and that 1 have mad and understand thc Information No[ice Io lhx~pefty Owners about Construetton Reapon ~ibilities <br />on thc mwr~e sid~ of th/s form, <br /> <br />Name ~f A[~plicam (p case pISnt~ · . : Phone: <br /> <br />sarvlcc or plumbthg water/sewet lines are separate requjred permits, q r l 3qa0 MC15-$4 R,vll,gl <br /> <br /> <br />