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( ~ ArraYed <br />Comm~rCi~( ) Naw( ) Roplacemant( ) ( ) Detached <br /> <br />g,dal#: ~]t~/0'-~'/ Mannfactur~: /q~,~ Approve~Lab~l: ............... ~7 / <br /> <br />Location of Insmlhtion zq# ~' ~ 7~7 f- <br /> <br />3. Contractor Information <br /> Owner I Mailing Address IPh°nc No. <br /> <br /> ( ) I own, reside in, or will reside in the cornp!ctcd struaur~, : <br /> <br />· ( ) I understand that I. must reglst~r as a const mctiem, bomractor if th9 structure b sold or offereO fpr s.a,!9 bdpr~ Or upghiioomplc6on, <br />( ) I will bo my own g~neral contra~or, <br /> <br />If I hire subcontractors, I will hire only subcontractors regist~e~ with the Consuucdon Contractors Board. <br />If I change my mind and do hire a general eontrac:or, I will contract w~th a cantractor who is registered with the COnstruction Contractor's Board, and will <br />~ec/~ately no~y Marion County ~ ,~e. n.a.m~ of th~ ~ontra~or. ~,e~ q}g ',, ' <br />( )I ama rcg~s~re~'buildet OR th- e authorized re~' f~re~ntativ' ~"~ re~iste~ heilder. /~ ]~ ~_., ~r'~' 773,).'5 ,' ~", ..... <br /> · T 'Tf ...... / <br />Authored agent o~leasee: [~afling Add.ss' I Phon~: <br /> <br />4, Fee Schedule <br /> <br />A. (1) Manufactured Home <br /> or Modular Unit Phcemenl/Ctnmectlon <br /> <br /> (2) State Fee <br /> O) State Sureharge~ <br /> <br />TOTAL: $ <br /> <br />B. (1) Mfg.'d Structure Storage Fee <br />(2) Mfg.'d Structure Storage Renewal @ 25.00 = __ <br />(3) Zoning Surcharge (15.00 ff applicable) @ J~5.00 = <br /> <br />@ 40.00 per hour (2 hoar minimum) <br /> <br />@ $60.00.~__ <br /> <br />@ $40,00 =__ <br /> <br />I hereby cenll'y that thc above information is correct ~nd that I hev* read and tmderstand the ~nformation Notice m Property Ownel'~ abou[ Construction Rcspon~ibiliaes <br />on the ~verse side of this form, <br /> <br /> MC 1544 R~v 11-91 <br /> <br /> <br />