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, ' MARION COUNTY BUILDIN~P..~.CTION <br /> FO~)F~.I~E. .?SdE2,N~L~YI I\ ~ 220 ~igh S~[~ ~JFOR OFFICE USE ONLYI <br />Received b~.~l ~ a S~m, OR 973~ ~/~sat~a~ Req~r~ s <br />] Z°ning Vah~ti9~2 ~.~ ] ~' <br /> <br /> ~O~L~T8 ALL SEC~ONS, 1 ~OUG~ 4 PER~TAPPLICAT~ <br /> <br />Rcsid~naal( ~') New0-~'J'~ : P.~placemmt( ) ' 'q),,~/ Gauge or C~o~ <br />C~me~al( ) New( ) , R~c~mt( ) ( ) Attach~ <br /> , ( ) Daached <br /> <br />2. Location of Installation ff~u~, ~ ~ 7~7 5- <br /> <br />Subdivision ' ; LO~ [Bl~gk Urban Growth Bounda~? <br /> <br /> ¢ ' ' . <br /> ~e ~ Map W~r Su~ly'~ <br />LoIWi~ ~'1 ~ ~g/ Aema ~g-~t ~ Com2r~" Pfiva~W~ ( ) Spring <br />" , : ...... O ,, 0 C~mu~ty W~ ( ),,,~ty <br /> <br />3, Contractor Information <br /> <br />( ) I own, reside in. or will m~ide in thc completed suucture. ; <br /> <br />( ) I understand that I mm~ m~s~r as a eonstmefien contrac~r ff be stm~ure is sold or offend for s,,~e b~og or upon cemple~on, <br />( ) I rag ~ nay own ge~e~d e~atra~or. <br /> <br />If I hlr~ subcontractors, I will him only subcontractors l'~gis t ea'M with the Constmeaion Comtaetors Board, <br />~f ] change my mind and do hi~ a g~neral oolltractor~ I will colltract with a ~ontvactor who is r~gistered with th6 Constnl~tion Contractoc's Board, and <br />immediately notify Marion County of ~e name of thc contractor. <br /> <br />4. Fee Schedule <br /> <br />A, (1) Manu~a~u~d Home <br /> <br /> or Mod-hr Unit ~acemen~Conneefion <br /> <br /> (2) State Fee <br /> <br /> (3) State Su~a~e <br /> (4) ~ Surge (l$,~ffapp~eable) <br /> <br />B, (1) Mfg.'dStmetureStorageFee (2) Mfg,'d Stntetum Storage Renewal <br /> <br /> O) Zoning Surcharge (15.00 J.f appl/eable) <br /> <br />C. Additionallnspectloa @ $60,00=__ <br /> or Re. inspection <br /> <br />D, Invosfigarion Fee <br /> <br />@ 40.00 per hour (2 hour minimum) <br /> <br />@ $40.00 <br /> <br />TOTAL= <br /> <br />i hereby certify that the above information is correct and that I have read and understand the information Notice to Property Owners about Construction Responsibilities <br />on the ~ve.r~e side of this form. , <br /> <br />Name of Applicant (plea ..... ~ ,, ; Phone: ~ <br />MC 15-64 Rev 11-91 <br /> <br /> <br />