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/~ / 220Rig~S~t~ [~ ~~E USE ONLY
<br />Received by, ~77~ { ~,~ i~/a~ S~m, OR 97301
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<br /> MANUFACTURED STRUCTURE PLACE~0~
<br /> ~Tg ALL S~C~ONS, 1 T~OUGH 4 PER~T APPLICATION ~ vvUi~ ~'~
<br /> 1, Job Desc~fi0n ~[DIN6 I~SPECT;O,~
<br />
<br />Cornmemial( ) New( ) Replacement( ) (( )) AtmchedDetached ....
<br />Manufaeturees" Year of ~lor
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<br />2. Location of Installation ~ y~0..~.
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<br /> Sim No.
<br />Su~i'cislon ' '" ; ' LotI ,,, ,IBlr~q ' :
<br /> Pfivate W~ ( )Spmg ( )
<br /> Width ~l .... ~ m~h ~ t A¢~ ~e~. ~t, ~. C0m~ ~ m~mumty W~ ( ) ~[y ( ,,,,>,
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<br />3. Contractor Information
<br />
<br />( ) I own, rc$1d~ in, ~r wLll r¢~de in the eomplete~ strUCture, .
<br />
<br />If I him subr. ontra~tors, I will h/re only subcontractors r~gistered with [he COnStmctlon Contractors Board.
<br />If I change my mind and do h~re a general contractor, I will contract with a Cmtranmf'who i~ registered with *he Constmefion Contractor*' Board, and
<br />manedtatelyno~yManonCoumyofthenameofthecontractor, d~ ~ '
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<br />4, Fee Schedule '
<br />A. (1) Manufactured Home
<br />
<br /> or Modular Unk Place, me.r/Corm eetion
<br />
<br /> (2) S~ato Fcc
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<br /> 0) 8tat~ Sure, hargo
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<br /> (4) Zotfing Surehalge (I5,00 ffapplieable)
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<br />B, (1) Mfg.'d Structure Storage Fee (2) Mfg.'d Stmctu~ Storage Renewal
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<br /> (~) Zoning Surc,,hal'ge (15,00 if applicable)
<br />
<br /> @ $182,00 = /~' ~ C. Additional Inspection
<br />@' 20~00= ' :" :. Or Relnspee~0n ::
<br />.. 9.10~-: ~-/,tO ' .:
<br />@ ~ ~...0 D. I~ve~ga~ot~:Fee '
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<br /> TOTAL $.~- ~/0 E, 0ther~spections not lismd
<br />@ 15,00 = :
<br />
<br />40,00 p~r hour (2 hour mm'a)
<br />
<br />@ $60.00 =
<br />
<br />:@ $40,00 =.,,,
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<br />[ hereby certify that the above information is correct and that I have mad and Understand the Information No0.ee [o Property Owner~ about Construct~oa ResponsiD~ties
<br />on thc reverse side of this~.~,~r ~.,. fo~. /.~ ~.
<br />
<br />This fee ¢OVer~ the manufactured stru~um plammem, plumbing connect/on, electrical conneetina and mechanical conneetlon, Site evaluation, septic pemfit, deetfical
<br />service or plumbing water/sewer lines are separate required permltg. MC 1 $.64 Rev 11-91
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