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MANUFACTURED STRUCTURE PLACEMENT <br /> PERMIT APPLICATION <br />COMPLETE ALL SECTIONS, 1 TFIR. OUGI 1 4 <br />1. lob Description <br /> <br /> JobAddve$~ Tax Ace[. No. Cross Strem <br /> ..... ~ ~r~ c ~ o ~. si~, ~o. ' .... <br /> Subdivisi~~O~ ~ ~ ~ /Im~k '~ VrbanG~wlhBomlda,? <br /> <br />Mobile ~I~cB~r~ .... . ~c~ Y( )N( ) <br /> P~vateWe~ ( ) Spring <br />l,~Wid~ ~ ~ ~tDe~ ~ 2 Acres ~ ,,, ~g.~t Comer Commumt~{ <br /> <br />3, Contractor Information <br />Prop~y Owner [ Mailing Address [Phone No. <br />( ) I own, reside in, or will ~side in the completed structure. <br /> <br />immedia~y aofffy Madoa Comty of tbe nam¢ of the eOnlractor.,-x A ^~ <br /> <br />4. Fee Schedule <br /> <br />A. (1) MaaufaetumdHome <br />or Modniar Unlt PlaeemenqConnect~on @ $I 82.00 r-.__ <br />(2) State Fee @ 20.00 =- <br />O) State Surcharge @ 9,10 =__ <br /> @ 15.00 =_ <br />(4) Zoning Sutchat'g¢ (15.00 if applicable) <br /> <br />TOTAL: $ <br /> <br />B. (1) Mfg.'d Structure Storage Fcc <br /> @ $ 25,00 <br /> (2) Mfg.'d Structure Storage Renewal @ 25.00 <br /> (3) 2&oning Surcha/ge (15.00 il'applicable) @ 15.00 <br /> <br />Marling Address: 1 Phone: <br /> <br />C. AddilSonal Inspection @ $60.00 = <br /> or Rc~nspectlon <br /> <br />D, ~nvcsdgatlon Fee <br /> <br />@ 40.00 ~r hour (2 hour minimum) <br /> <br />@ $40,(D = <br /> <br />/ %0 0 <br /> <br />I hereby certify that thc above iOformatlon is con~t and ghat i have mad and ond~rstand thc Information Notice to Property Owner; aboot Construction Responsibilities <br />on the mverso~side o1[ this form. <br /> <br />Sigxlatutc of Applicant: ~ ~ ~_~ · D4~ I D~a Dale: <br /> <br />'l~s fee c~ers ~e nlanul~ctu~d structure pla~ngnt, plumbing mnne~fi~, O~tfic~ c~on and mechanical comle~tJon. Site evaluation, scplic pem~it, electrical <br />semite or plumbing watet/sewe* lines am serrate r~ltired pemlts. MC 15 -64 Rev 11-91 <br /> <br /> <br />