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~/ BUILDING ~ MOBILE HOME ~ SEP~IN~~LICATION <br /> ~ed~"~ner: , '] Phone: <br /> <br /> Job ~dre~: ~ ~ 9~ No,: C~ ~eat: <br /> Prope,y <br /> <br />Su~M$1on: \ <br />Mobile Homo Perk: <br /> <br />L~e_c t~3~: Township; Range: I Zone; <br /> frmg, I.~t; <br /> <br /> Contr~tor Business Name and NO,: Phone: I Address: <br /> Architect/Engineer: Phone: <br /> <br />Block: <br /> <br />Total ~ Specee: <br /> <br />Type of Permit: <br /> <br />New: rm /~ Addlflee: I~ Demo; <br />Alter;~ Reloca~on: [] O~c. Chg.; <br /> <br />Height of Building: ] NO, Stories: <br /> / <br />Mobile Home MobJl~ HOF~ <br />Width; Lang.: <br /> <br />Toc~. <br /> <br />SCl, R, IVan FlOor; <br /> 4 <br /># Bedrooms: <br /> <br />ng:~ RES <br /> <br /> COM <br /> <br />Sq. Pt, Garage: I Other: <br />Occupant Load: t Water Supply: <br /> <br />Proposed ~eFl~ li't~ta, li~ierc <br />~.P.r~vlous Site Evaluation #; <br /> <br /> T~,pe of S/stem: .......... <br /> Tern FI~%~ Ready; <br /> , Wi!t ca, ii when holes ready: Proposed Bedrooms: <br /> Existing Sec, tlc System; <br />,,, Ex~stlm~ ~k Size: ~ ~ ~ ~. ~,,~ . <br /> Ex[~ Drainfield ~th: <br /> Type of 8~¢~em,. ~~ ~ ~'~j <br /> <br />( "~ ) H~weres~tltisaR~icationinitsemimtyandce~fythatthesta~lnf~mt~jo~ls <br /> <br />Valuation; <br /> <br /> SJdg. Fee: <br /> <br />Mobile Home Fee; <br />Fleet Surcharge: <br />Zoning Surcharge: <br />Stero Surcharge: <br />Plans Check Fee; <br />Site Evaluation Fee: <br />~ept~ Permit <br /> <br />DEQ Surchargm <br />Technical Review Fee: <br />ReinspectJon Fee; <br />InvestJ~gatiee Fee; <br />City Fee; <br /> <br />TOTAL FEEt <br />RECEIPT NO.: <br /> <br /> <br />