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~e-A-~ 588-7904 <br /> <br /> MANUFACWURED STRUCTUR~~ <br />COYOTE ALL SEC'HONS, 1 T~OUOH 4 PER~T APPLIC~}~N <br /> Job Doscrip~on <br /> <br /> ( ) Attached <br />Commumial( ) New( ) ~pla~em~t( ) ( ) Der<bed <br /> <br />M~ufa~umes Y~ar~ ~ ~ Color of ~g~: W~d~: <br /> <br />2, Location of Installation <br /> <br />SuMi~sion Mt [ BI~' ,,, ~rban O~wth Bounda~? <br /> Pfivam Well ( ) $ptk~g <br />L~Wid~ ~5't L~be~ )g~, Acres I~*g.~t ,,~ c°m~r ~ ,,9ommumtyWell( ) City <br /> <br />3. Contractor Information <br />P~op~t¥ Owr~r ~ o~' ~ ~g Adth~a~ <br />(~) I om. msMe in, or ~dl ~side ~ the mmplemd smau~, <br /> <br />( } I will be my own gmeral c~;nct~. <br /> <br /> ) I am a registered builder OR the authorized n~pmsentative of a registega builder. <br />' Authorized agent orleasee: Ct~/3,,Lt~i~....~ ]MailhlgAddress: .,, IVbo. :3 ,3 tTtl <br /> 4. Fee Schedule <br /> A, (I) Man@acttl~ed Home <br /> or Modular Unit PlaeemeaffConnection @ $182.00= /~32q_Z_,~'~ C. Addltionallnspe¢fion @ <br /> (2) State Fee @ 20,00 = o~ 10, ~ ' or Relnspection <br /> @ 9.I0 =-~-~, ~9 <br /> (3) Stat~ Surcharge @ -15,99= e~,~dS) D. Invest(gafion <br /> <br /> B, (1) Mfg.'d Stmemm Storage Fee @ 40.00 per hour (2 hour minimum) <br /> @ <br /> (2) <br /> Mfg,'d <br /> Storage <br /> <br /> (3) Zooing Surcharge (15.00 il' applicable) @ 15.00 = ,-- <br /> <br />I hereby certify that the above itfformatlon is correct and that I~ have mad and uaderstaud the [aformatlon Notice to Property Ownem abcglt Ccmstruedon Respcyasibililies <br /> <br /> <br />