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MANUFACTURED STRUCTURE PI~Cu~MJ~NT <br /> PERMIT APPLICATIOJS~trlatltON UO~JNTY ~/a~..~~ <br />1. Job Description <br /> <br />2. Location of Installation ,, , ~.¢..~..,.f O ~ l/eL ~r'~ q 73,J~- <br /> <br />~ohA~d~s ~$5' l~el/e vt~ ~_ 7~ r ?~^~ No. <br /> fftl~lStJtl/,e_ ~r~ qTJFgSF ISit~No. <br />Subdivision · [ Lei ] Blcmk <br /> <br />I Urban Growth Boundary? <br /> <br /> Y( )N( ) <br /> Water Supply: <br /> Private Well ( ) Spring <br />I 9°mmunity Well ( ) C~ty <br /> <br />3, Contractor Information <br /> <br /> ) I o~, msMe in, or ~ reside ~ ~e c~c~d ~tmaum. <br /> <br /> ) I unde~nd ~at I must ~smr as a const~c~ c~r ff ~e s~ is sold ~ offend for sale befo~ or u~n c~plefion. <br /> <br /> ) I wffi be my own gmeml <br /> <br />If I him suhaontractors, I vail hire only subcontractors registered with the Construction Comr~ctors Boa~, <br /> <br />If I change my mind and do hi~ a genera contractor, I will contract w/th a c~mtraet~r who is m~stemd with thc Constmctlon Contractors Board, and wilt <br /> <br />immediately notify Marion County of the name of the contractor. <br />ContractorBuslnesaName&#:~ff~/-/jq~.~ d#tln~._~,, <br /> t qqo ]'UailingAdd.ss: ~t14'~__~ ~ ~.~Phone; <br /> <br />( "~J~am a registered buRdc~r OR the authofizr~d l~pr~s~mlative of a registered bnilden <br /> <br />4. Fee Schedule <br />A. (1) M~nufacaumd Home <br />or Modular Unit PlaccmenffCaaneefion <br />(2) State Fee @ <br /> <br /> (3) Slate Surcharge <br /> · ' able~/~TOTAL <br />B. (1) Mf$.'d Structure Storage Fee <br /> @ $25.00=__ <br />(2) Mfg,'d Structure Storage Renewal @ 25.00 --__ <br />O) Zoning Surcharge (15.00 if applicable) @ 15,00 = <br /> <br />C, Additional Inspect{aa <br /> or Rnimpectlon <br /> <br />D, Invesfigafon Fee <br /> <br />E, Other inspections not listed <br /> @ 40,00 pe~ hour (2 hour mkdmm'n) <br /> <br />I hereby certify that the above information is coffect aBd that I have mad and under~tand the Information Notice to Property Owners about Constmctio¢~ Respon sthilltie~ <br />on the reverse side of this form, <br /> <br />This fee covers the manufaculred sU'0ctot~ placement, plumbing COnnection, electrical connection and mechanical connection. Site evaluation, scpI[¢ permit, electrical <br />service or plumbing water/rower hnes am separate required permits. MC 15-64 Rev 11-91 <br /> <br /> <br />