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', MARION COUNTY BUiLDiN~t~ECTION <br />· ] FOR OrFIC USE ONLY[ 220 High Street FOR OFFICE USE ONLY <br />/ Recelved by <br />/ Zoning Validatio~ <br /> <br /> MANUFACTURED STRUCTUR~LAC~T <br /> PERMIT APPLI <br /> C O~LETE ALL SEC"ONS, 1 T}IROUG" 4 <br /> <br />2. Location of Installation ~] a_ t4n£d~ }/~, q'73.,? S~ <br /> <br /> amtu, q s .No, ' ...... <br />~Ub~si~ ~ ....... La I ~,1~ ...... Urban Growth <br /> <br />Se~ioa ~fi' ~bwas~p frs Range ~ ...... ~e ~ Map WaterSu~ly, <br /> ................. Pdva~eWe~ ( ) Spring <br />~Wid~ ~--~/ L~ De~ O~r Acres I~g, ~t ~ff ...... Comer ~ Co~muait7 We~( <br /> <br />3. Contractor Information <br />' Property Own¢~ ~'~ I Marling Address ....... IPho~ NoI '' <br /> <br /> ( ) ! own, ~e~ide in, or will mdde in the completed structure, <br /> ) I undersumd that I mu~t r~glster as a eonstmefion 6,ontmc~rt if the stmoture is sold or offered for sale before or upon completion. <br /> <br /> ) I will be my oven general eontrae[or. <br /> <br />If I hire subcontractors, I will Mx~ only subcontractors registered with the Conshalctioi1 Contractor~ Board, <br /> <br />If ! change my mind and do hire a general contractor, I udll contract with a cemraetor who is registered with the Construction Contractor's Board, and will <br />inuned~atel¥ notify Marion County of the name of the contractor, <br />C°mra~or Business Name & #;-J39/v~~m'/.-r. .... ,, ,w ~,,~41~ .... Ot*o,'/.,,~.u t'ru iI MuillnS Aaa~s~',S~c,a~-rr~x.~ / ..... ~, ~'ho~e: 7&c2_ 77qS/ <br />( ~ am a tegisterexl builder OR the authorized representative of a registered builder, ...... <br /> <br />Authorized agent or le~sce:~C~..~ <br /> <br />4. Fee Schedule <br /> <br />A. (1) Manufactured Home <br />or Modular Unit Placemmt/C. onneefion @ <br />(2) State Fee @ 20,00 <br />($) State Surcharge @ 4k443~-- <br />(4) ~ng Sumhage (15,~if applicable) ~AL: <br /> <br />B, (1) M£g,'d Structure $~otage Fe~ <br />(2) Mfg,'d Stroctufe Storage Renewal @ $ 25,00 <br /> @ 25,00 <br />(3) ~tlng Surcharge (15.00 if applicable) @ 15.00 <br /> <br />C. Additional ~lspe~tion <br /> or Relnspection <br /> <br />D, Investigation Fee <br /> <br />ici, Othex inspectlons not listed <br /> @ 40.00 per hoot (2 hour mlniracra) <br /> <br />@ $60,00 := <br /> <br />@ $40.00 =__ <br /> <br />Signature of Applic~ Phone: <br />MC 15-64 Rev 11-91 <br /> <br /> <br />