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FOR OFF!CE USE ONLY MARION COUNTY BUIL~ING~N,~PEi~TION, FOR OFFICE USE ONLY <br /> - .... <br /> <br /> /~//~/0/ 8 00 a m 4::30 p m Phone =~147~ <br /> Code-A-Phone ~8-7904 ~ ~ ~ <br /> Left Side:: /~ /[ Right Side:: /~ <br /> FAX 588-~48 ~ ~ ~: ~. & <br /> _ ;~"~',? CuE~ y <br /> MANUFA~URED STRUCTURE & SE~ ~R~ICATION <br /> <br />[[l~'~ Single Family Dwelling [ ] Offu:e [ ] Classroom [ ] Slarage I <br /> [/RES [ I eOM [~ew [ ] Storage [ I O ce. Chg. [ I Replacement [ ]Technw~Review <br /> I <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. Location of Installation <br /> <br />2. Installation <br /> <br />, Pml',eny~ Mailing Addm~ &: Pho~ No. ']&9- '7 <br /> <br /> Auth Agen~ Mmllng Addmsa & Phooe No, <br /> <br />Comra~Or Business Nme & Number Mailing A&ln:~ & l~m~ No, <br /> <br />P~ No, B~s: ~g Nm B~m: N~w~ D <br /> <br />~sed ~ Ev~uafim ~ <br />Te~ lt&m ~ ~ W~ ~ T~ H~es R~y ~ <br />Ex~g Si~ ~ ~ ~ 8~ Ev~u~ No: <br /> <br />~s~g Se~e Sysmm ~ <br /> <br /> / <br />[ {~¥I have r~ad this apphcafion m itz entilgty ~ ~ ttff'y that the stated Jnfommlion is Lm~ ~d <br /> oormc~ to Ibe best of my knowhxlge, <br />[ 1 I~lf~peff°rmmgwoek~aapropertylownmoccupy,, <br />[etq~fa ,~.~ hurter OR [ ] the aum,:..ma rep~tatl.~ or a <br />[ [.~Tbe~.~ork ~ be lmdo~n~:l by a mgi~lemd builder. <br /> <br />~ I agree to braid according m t~e[uhmttea plans ~d sl~&~iea~c~s, the law~ of~e <br /> <br />Signatu~ of Applicant {~-~ <br /> / / <br /> <br />4. Fee Schedule <br /> <br />A Each Mfg,'d IIorne or Modular Unit <br /> <br /> Base <br /> Each M£g, 'd llome or Modular Unit <br /> <br /> State Fee <br /> <br /> Electrical Service <br /> <br /> (1) Total of Abow <br /> (2) 5% State Surcharge (05 x Al) <br /> (3) Zoning Surcharge (05 x <br /> Subtotal <br /> <br />B Mfg'd Structure Storage Fee <br /> Mfg'd Stmcmm Storage Rene,~ al <br />C Sim Evaluation Fee <br /> <br /> @ $4000 per hour (2 hour m~ ) <br />K, City Fee <br /> <br />TOTAL AMOUNT DUE <br /> <br /> Item x Cost = Total <br /> <br /> ./ 3~/,q,g o <br /> <br />__ 25 (X).__ <br /> 3500 <br /> 350O <br /> <br />25 00 <br />2500 <br /> <br />40 O0 <br /> £?...,~', <br /> <br /> <br />