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( ) Attached <br />Comme~mial( ) : New( ) Replaeammt( ) ( ) Detached <br /> <br />2. Location of Installation <br /> <br />Mo~eH~ePa~ . S~ee~ , I Y(' ) N~ ) <br />Se~on ~ I To.aMp ~nge Z~e Map Wa~r Su~ly; <br /> Private Well ( ) Sp~g ( ) <br /> <br />3. Contractor Information <br />Propeay Owr~r , , [ Mailing Address [Phone No, <br /> <br />( ) I ~fle~d ~at I must ~s~r as a ~stm~ e~r ff ~e stm~ ~ sold or offe~ for s~e ~om or u~a c~plefion, <br />( ) I ~ ~ my own gmer~ <br /> <br />:4, :Fe~. Schedule. <br /> A. (1) Manufa~umd Home <br /> ot Modular Unit Placem~dCcemecfion <br /> <br /> (2) Stato Fee <br /> <br /> (3) State Sumha~e <br /> (4) ~ (15,~ ff app~eab~) <br /> <br />B, (1) ~g,'dStm~um$~ngeF~ <br /> ¢) ~g,'d S[m~m Storage R~ew~ <br /> <br /> (3) ~ing Samha~e (15,ffi ff a~able) <br /> <br />If I ~ subcontractors, I will hi~ on17 suboantraciors m$iste~ wi~ ~e ~s~i~ ~mm B~rd, <br /> <br />( ) I ~ a mg~md b~det OR ~e au~o~d ~s~a~w of 7 ~gBt~ ~. <br />Au~o~ag~tor~asem ~ , ~i,//~ ~ ]M~gAddmss;D~ o t/~ [ Phone: ~ ~/._ ~ 7~'~ <br /> <br />@ $ ~.00= , <br /> <br />@ <br /> <br />C. AddkionalInspec6vn @ $60.00=__ <br /> or Rei~apect/on <br /> <br />D, lavestigafion Fee <br /> <br />E, Otheri~spections not hstcd @ $40.00 <br /> @ 40.00 t~r bout fl hour minimum) <br /> <br />I hereby certify that the above information is come. ct and that I have ~ad m~d ~mderstand thc Information Notice to Propercz Owners about Construct o Responsib it/es <br />on [he reverse aide of this form, <br /> " ' ~'Phone: .... <br /> <br /> MC 15-64 Rev 11-91 <br /> <br /> <br />