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~ ' MARION COUNTY B~'IIIIII~G INSPECTION <br />FOR. OFFIC_.kE USE DNLY 220 ~4/~;¢~/'~'- [FOR OFFICE USE ONLY <br /> I aeceaved by: ~'~-~/~tz~. I Sal~3~ I~__ <br /> [ Zoning VaHdatioD~ e/? 8:~-4:~eSss~:~- ~"-5147 ~/~J~N ~ <br /> ' ~ ~ ~-A-~ 04 ' ~ ¢ ' " <br /> <br /> COYOTE ALL SEGIION5. 1 T~OUOH <br /> <br /> Manufacmmga Year of Co~r ~ L~gth: [ Wid~ <br /> <br /> 2. Location of Ins~llafion ~ur~ ~/~ ~4 7 / <br /> <br />Property Owne, ~q ig Mailing Address t o Phone No. <br /> <br />Subd~s~on L~ I Bl~k Urban G~wth Bounda~7 <br /> ......... l'~vateWeg ( ) Sp~g ( ) <br /> <br />3. Contractor Information <br />Pro~ny Owne A ~ <br /> <br />Mailing Addms~ [ Phone No, <br /> <br />( ) I will be my own general contractor. <br /> <br />If I hive subcontractor% I will hire only subcontractor~ regjstcrexl with the Construction CO~ltractors Board, <br /> <br />]ff I change my mb~d and do hire a general contractor, I will contract with a ccatraetor who is registered with thc Construction Contractor's Boa rd, and will <br />imraedlamly notify Marion County of thc name of tho contractor. G/;(gg/j~F;-Z ~/~t4;~d!~ 14/~ 2 ~ <br /> ,' '. ' /7a77 IPho. : <br /> ContractorBus.nessName&#' t #~/?~'t~ 9~a~ ~ [MailingAddmss: <br /> (.,,¢')'~lamaregist~mdbuL!d~theauthofized~l~scntativeofavegisterexlbuilder. ['2~ .¢ld i/d d~ Pd ~'~ ~ / ~'I ~ / ~ , Orr. '17 0 3 g <br /> A~thodzed agent or leas : Mailing Address- <br /> <br />4. <br /> Fee <br /> <br />A. (1) Manufactured Home <br /> <br /> or Modular Unit Placement/Connection <br /> <br /> (2) State Fee <br /> <br /> O) State Surcharge <br /> <br /> (4) Zoning Sumbarge (15.00 if applicable) <br /> <br />I~'~0 :~, ~O C. Additlonal Inspectlon <br /> 20.00= ~, d'g~ or Reinspeetlon <br /> <br /> ~ ,.,,~/.. 7~ D. Iavestiga6on Fee <br /> <br />B. (1) Mfg.'d Structure Storage Fee <br /> @ $ 25.00 <br />(2) Mfg,'d Structure Storage Renewal @ 25.00 <br />(3) Zoning Sumharge (15.00 if applicable) @ I5.00 <br /> <br />@ 40,00 per hour ('2 hour minimum) <br /> <br />@ $60,00 ~__ <br /> <br />@ $40.00 <br /> <br />I hereby cerilfy that the abov¢informatlon is correct and that I have read and ~ idersmndlhe Information Notice to Properky Owner~ about Const uctio Respon~ibLljtics <br /> <br />This fee ¢ov¢~ctuted tu;6"~cture plantar." [. plumbingLne;fion, ..tncal connection and mechanical connection. Sk¢ evaluation, s<'plic ..it. electrical <br />aervice or plumbing watet/~ewer Ilae~ ave ~eparate rcqulmd permits. MC 15-64 Rev 11-91 <br /> <br /> <br />