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MARION COUNTY BUILDING iNSPECTION <br /> <br /> Salem <br /> <br /> PAX 588-7948 <br /> <br />FOR OFFICE USE ONLY <br />CiLy Setback Rcqulrem~nts', <br /> <br />~ront: ID / Rear: /~ t <br /> /.5- ' Right Side:/..,~/ <br /> <br />COMPLETE ALL SECTIONS, I THROUGH 4 <br />I. Job Description fl;~..-~ <br /> <br />2. Location of Installation <br /> O =r I Ual g dd s // <br /> <br />Subdivision <br /> <br />Depth ~/ Acres <br /> <br />LotWJdth ,t.~,-~,~ / <br /> <br />Contractor Information <br /> <br /> ,#la ~,rd///,.,, ~C~. q <br />T~ Acct. No, Cr~s Street <br /> <br />8i~eN~ <br /> <br />Lot I Block <br />Space# /~ <br /> <br />Z~me /~ Map <br />Irreg. Lot ~ Comer A/tO <br /> <br />Y( ) N<L¢~/ <br /> <br />Priva~Well ( ) Sprig ( ) <br />C0mmunit¥ Well.( ,, ),,,, (2ity <br /> <br />Mailing Address I Phone No. <br /> <br />) I own, reside in, or will reside in the completed structure. <br /> <br />) I understand that I must l~gister as a comtmction contractor ff the stmetur~ is sold or offe.~d for sale before or upon completion. <br /> <br />) I will be my own general contractor <br /> <br />If I hire mboonlxaetor% I will him only subcontractors registered with the Constmctlon Contractors Board, <br /> <br />If I change my m~d and do him a general e~tlkeaegor, I will contract with a ¢¢~lkra~tor who is registered with the Congkmctioa Conlractor'a Boa rd, and wiI1 <br />immcdlatcly notify Marion Cmmty of the name of the contractor, <br /> <br />( ~m a registered bulkier OR the authorized mlXeSenta~ive of a registered bnilde, <br /> <br />4. Fee Schedule <br /> <br />A. (I) Manu£aaured Home <br /> <br /> or Modular Unit Plaeemmt/Conneet/on <br /> <br />B, (I) Mfg,'d Stmctore Storage Fee <br /> (2) Mfg,'d Structure StOrage Renewal <br /> <br /> (3) Zoning Sureba~g¢ (15,00 if applicable) <br /> <br />{M~gAddress: //~ 73 <br /> <br />@ $60.00=____ <br /> <br />TOTAL:$ ,_~/~'f$O E. Other Jmlx:¢tiC~snot llzted @ $40.00=__ <br /> ~ 40.00 per hour ¢2 hour m/n/mm) <br /> 25.00 =,__ <br /> <br /> 15,00 = <br /> Rr, cnrpr: <br /> <br />] hereby eof lily that the above inl'otmation is cermet and that I have read and underatand the Information Notice to Property Owner~ about Construction Respons bll fica <br /> <br />Ni,.me °f APpbeaat (PI ..... Phone: 7~6ff-FF~ <br />Signature of Applieant~ Date: T~ ~ <br /> <br /> MC 15-64 Rev 11.91 <br /> <br /> <br />