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MARION COUNTY BUILDING INSPECTION <br /> 220 High S~/'~ ~ ~ ~,_ IFOR OFFICE USE ONLY <br /> <br /> ~e-A-~ 1~79~ ~ I',i;; ~%~ ~ ',~d~ ' <br /> MANUFACTURED STRUCTUR~Arfi~ ~ <br />COYOTE ALL SEC~ONS, 1 T~OUGH 4 PER~T APPLICA~0~ <br /> <br />FOR OFFI~E~.U~SE~. ONLY <br />ReceDed by:~' <br />Zoning Validatio~'f' ~r_~. <br />Date: ,,ff-l--9/~ ' <br /> <br />Residential(-~ New( ~ Replacement( ) ~'u! IU/~ Ga~o~a~_,~,) <br /> (~) At~ <br />Co~e~( ) New( ) Rephcem~t( ) (' ) Detached <br /> <br />~ofSi~g:~ ~/_// ~ofR~fmg: ~~ ISq. F~mge: /~p No. Bedmms: ~ <br /> <br />2. Location of Installation <br /> <br />JobAddmss~g~ ~)~~~ ~ T~Acc~No.~/ ~-~/ CrossSt~et~/~ ~ <br />~u~si~ ~ [ Bilk Urban Growth Bounda~? <br /> Private WeH <br />L~ Wid~ ff~ ~ De~ /~ Acres ~eg. ~t ~ Comer ~O CommuNty Wen ( ) City <br /> <br />3. ConWactorlnformafion /7..ff6' -f 4,t ~ ct ,.e '"/' .'gaV <br />PmpertyOwnerZT"~jt.~& ~ [ Mailing Address ,.ft~-4..-_-_-_-_-_-_-~j ~9~, q,7~t~Z.-4Ph°neNo. <br />( ) I own, reside in, or will reside in the complded structure. <br /> <br />( ) I understand that I must register as a construction contractor ff the structure is sold or offered for sale before or upon completion. <br /> <br />( ) I will be my own general contractor. <br /> <br />If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. <br /> <br />ff I change my mind and do hire a general contractor, I will contract with a contractor who is registered with the Construction Contractor's Board, and will <br /> <br />immediately notify Marion County of the name of the contractor. ,.,C/J"/~P'~ -~)~:. <br />ContractorBusmessNamc&#:~4.1O, yDL. ~I/-t~t,~/O~.t~ ~l{l~'~,tO JMaiUn, Address.~,9..t.~-~,, ~'?~'J,, J Ph°ne:gt,,J~l'I t! <br />( ~ a registered builder OR th*' e authorized representative of a registered builder. <br /> <br />Authorized agent orleasee:/~,~<~ et'~/~ I am"'Address: Iph°ne: t/C: <br />4. Fee Schedule <br /> <br />(1) Manufactured Home <br /> or Modular Unit Placement/Connection <br /> <br />(2) State Fee <br /> <br />(3) State Surcharge ~ ,...- / <br /> <br />4 <br />( )..Tamiag-SmCha,~ ~ .... i~ ,~plaac---~ble) <br /> <br />(I) Mfg.'d Structure Storage Fee <br /> @ $25.00=__ <br />(2) Mfg.'d Structure Storage Renewal @ 25.00 = ~ <br />(3) Zoning Surcharge (15.00 if applicable) @ 15.00 = ~ <br /> <br /> @ ~~--~4~,~ ~'~ C. Additional Inspection <br />@ 20.00 = ~ ~ or Reinspection <br />@ ~ <br />@ .~"--._~_,73~' D. InvesfigafionFee <br /> <br /> TOTAL:$ ~,~14/~ E. Other inspections not listed <br /> @ 40.00 per hour (2 hour minimum) <br /> <br />@ $60.00 <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 reverse side of this form. <br />Name ofApplicant (please Phone: 70'//_ .Z-7 <br />Signature of Applicant: Date: <br /> <br />This fee covers the manufactured structure placement, plumbing connection, electrical connection and mechanical connection. Site evaluation, septic permit, electrical <br />service or plumbing water/sewer lines are separate required permits. MC 15-64 Rev 11-91 <br /> <br /> <br />