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MARION COUNTY BUILDING INSPECTION <br /> 2201Righ StreetNm ~ FO_..__~R OFFIC~E USE ONLY. <br /> Salem, OR 97301 /] Oq'/~l/ city S~tbaea Reqdr*-n~t,: <br /> 8:00 am-4130pm Phone 588-5147 Front: ~/O t Rear: [t~ t <br /> Code~A-Phm',e 588-7904 ] Lifft SiC'g: /~- t [Right §'iae:/ S-, / <br /> FAX 588-7948 <br /> <br />Received by: f? <br /> <br />Date: lB -X/ . <br /> MANUFACT~ED STRUCTURE PLACEMENT <br /> COYOTE ALL SEC~ONS. 1 T~OUGH 4 P~R~APPLICATION <br /> 1. Job Descdpfion ", ' <br /> <br />3. Contractor Information <br /> <br />own, reside in, or will n~side in the completeg s~mott~re. <br />understand that I mtlst register as a const~l¢Ii~ contractor it' the stractt <br />will be my own gea~etal contractor, i <br /> <br />[BI~ Urban Growth Bounda~? <br />Map Pfiva~We~ ( ) Spring ( <br /> <br />m J3 ~:old or offered for sale be. for~ or ulxan ¢Ompletio~l, <br /> <br /> Ii* I him subcontractor% I will him only subcontractors regislemd with the COnsimciion Coutractor~ Bo~, <br /> If I change my m~nd a~l do him a genera[ cotltra~tor, I will court, act wlg~ a ~tmetor wlxo La resistel'~d Mill the Construction Coutraetor% Boar~l, and will <br /> immexliately notify Marion County of the name of thc ,ontraeto~l;~flr~.,/./,~[ i i <br />",,( ~ ) I am a mgi~te~*4 builder OR the authorized rept~se, ntatlw~ or · resisI~md builder. <br /> Authotjygd agent orl0aa~e: [A_~b. ,~ , i M,ailingAddress: <br /> <br />4. Fee Schedule <br />A, (1) Manufactured Home <br />or Modular Unit Placem~ml/Conno~ion <br />(2) Sram Fee <br />O) State $orcha~ge ' @ <br /> <br />(1) Mfs,'4 Stracmre Storage l%e <br /> <br />(2) Mfg.'d Structure Storage Renewal <br /> <br />(3) Zo~llng Surcharge (15.00 if applieablo) <br /> <br />@ <br /> <br /> TOTAL:$ ~/~ ~ <br />@ $ 25.00 ~-. <br />@ ~.00= <br />@ 15.00 -- <br /> <br />C. Addi~onal Inspection <br /> or Raimpeedon <br /> <br />D. Investigation Foe <br /> <br />E, Othg inslJeetion~ not listed <br /> @ 40,00 l~r hoot (2 hour minimum) <br /> <br />@ $60,0O:=__ <br /> <br />@ $40,00 <br /> <br />TOTAL--- <br /> <br />I hereby c0rtffy that the above information is correct *ad that 1 have raid and ufld~ta~d the ~fomafim Nodce m Pr~eRy Ownert about C~structlon Respon~ibilkie$ <br /> <br />Signature of AppECant: o,= <br /> ,, <br /> <br /> MC 15-64 Rev I1-9I <br /> <br /> <br />