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MARION COUNTY BUILDING INSPECTION
<br /> 220 High su~et NE ' : [FOR OFFICE USE ONLY1
<br /> ~:t.,oam-m.~l~lnrnone~-;~lr ~ I,~ ~ F ~' ~ ~ / Rear-
<br /> A-~ 588-9 , , . ~ ,
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<br /> · MANUFACTURED. STRUCTURE PL~C~ ~2 ]~
<br />COYOTE ALL SEC~ONS, 1 T~OUGH 4 PER~TAPPLICAHON ~ ~"
<br />L w ption M RION
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<br />Commercial( ) New( ) ....... Rephcemmt( ) '(v~Q DetaCh,ed '
<br />Manufactu~er'sOb-YT'OtK¥Tc/ Ycarof ~] / Colorof Length , Width;
<br />Serial #: / t ~ 57.,,,1,,'] M=urao~: ^pp.,ed t.ar~t: ....... 3 Z' Z
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<br />2. Location of Installation SAIL
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<br /> ,,, .... ' .... , aL, "'
<br /> No, , ...........
<br /> Pfiva~W~ ( ) Sprig
<br />L~wiua,/OI, q7 ~lO1,~ Aems ~eg. Mt Comer ~mmu~tyWe~( ~ Clty
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<br />3. Contractor Information ~'
<br />Prol~r~y Owner ] Mailing Adth~ss [Phone No,
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<br />( ) I own, i~dde in, or v~l reside ~ the completed stma~.
<br />( ) I understand that I must mglster as a conslraetic~ contractor ff thc stmctur6 is sold or offered for sale before or upon completion.
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<br />ff I hire subcontractors, I x~fil,I hire only sub¢octtacwrs registered with the Construction Contracioi~ Beard.
<br />If I change my mind and do hire a general eomractOr, I vail contract with a contractor who is re$1stemd with the Congtt~l~tion Contractor's ]~oa ed, and will
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<br />immediately notify Marion County of the name of the contractor. '
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<br />Mailing Addiess: j Phone:
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<br />( ) { am a registered builder OR the authorized representative of a registered builder,
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<br />4. Fee Schedule
<br />A. (I) ManufactumdHom¢
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<br /> (2) State Fee
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<br /> (3) State Surcharge
<br /> ~/~Zonlng Sumharge (15.00 if
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<br />B. (1) Mfg,*d Stmctux'e Storage Fcc
<br /> (2) Mfg.'d Structure Storage Renewal
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<br /> (3) Zoning Surcharge (15,00 il'appLicable)
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<br />Mailing Address/
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<br />.... , Phone:
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<br />@ ao.0o =
<br />@ 9.10 --..~Q
<br />@
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<br /> TOTAL: $ ,~.
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<br />@ $25,00=__
<br />@ 25,00 ~ __
<br />@ 15.00 =,. ,,
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<br />C, Additional In spectic~a
<br /> or Rcinspeoion
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<br />D, Investigation Fee
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<br />£07 $60.00 :=
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<br />E, OtherJnspeetioasnothsted @ $40.00=
<br /> @ 40,00 p~r hoar (2 hour minlm~m)
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<br />TAL-~
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<br />I hereby cer6fy that the above info.nation is correct and that I have w.~d wld understand the Information Notice to Ptopeay Owners about Construclion ResponsibJ~lles
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<br />Thi~ fee covers thc tnaeufa~aced structure Placement, plumbitlg comlection, eJectiical connectloB mid mechanical 'connection. Site evalt~alion, septic p~rmit, electrical
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<br /> MC 15-64 Rev 11-91
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