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AmOm CmJNTY SPECT ON <br /> , <br /> <br /> MANUFACTURED STRUCTURE PLACEMENT <br />COYOTE ALL SEC~ONS, 1 THROUGH 4 <br /> <br />1. Job D~cr <br /> <br />2. ,Location o£Installa~on ,,., /~ r/q$Ot~//~a ~t~ F_/?.~.~ 5- <br /> <br />Job Add.ss <br /> <br />, Map <br /> Comu~ ~0. <br /> <br />t <br /> <br /> Cross <br /> <br />Urban Growth Boundary? <br /> <br />Water Supply: <br />PrlvateWell ( ) Spring <br />Commu~!cy Well q } <br /> <br /> 3. Co~tractor la£onnation <br /> ''' ,, [mo No. <br /> <br /> Hlhimmb~ntmc~r%IwiE~ymbc~t~t~tegister~wi~eC~s~ionC~acm~Bmrd. [~fi~{O~ ~[~TY <br />~ I ch~ge my ~n~ and do ~ma general ~cmr, I wffi ~tmct M~a ~etor who ~ ~Os~er~d wi~ ~e Constmc~ ~~ <br />imedh~ly no~y Marion ~mty or the ~am~ of ~e c~tmcmr ~ <br /> <br /> Au~od~d ag~ or lease¢: <br /> <br />4. Fee Schedule <br /> <br />A, (1) ManufacmrM Home <br />or Modular Unit Placemmt/Connection @ $ I$2,00 ~ ~9, C <br /> (2) StateFee @ 20.00-- ..~,~" <br /> (3) State Surcharge @ 9'I0 ~ ~"/~} <br /> (gikZ~f~ieg $~! .qbh~le'~k/ll apphca~le) <br /> <br />B, (1) Mfg.'d Stmeture~ Storage Fcc <br /> @ $ 2fo0-- ~ <br />(2) Mfg.'d Structure Storage Renewal @ 25~O0 = ' : <br />O) ?~ning Sureha~e (15.00 ii applieab~*) @ <br /> <br />C, Ad ditlonal In spectic~ <br /> or Reimpe¢fion <br /> <br />D. Investigation Fee <br /> <br />g. Oth~ ins~c~ns no~ 1)s~efi <br /> @ 40.00 I~r hour (2 hour minlmum) <br /> <br />@ $60,00 =__ <br /> <br />$40.0O = <br /> <br />l hereby certify that the above information is correct and that I have read and understand the Infcqmation Notice to property Owners about Constmcffon Reapon~ibifitics <br />on thc t~verse side of this foml, <br /> <br />This fee cover~ the manufactured ,ql~¢lUm pIacemegh plumbing ~onneetion. o]ectdca] ¢oflngc~ion mid ))l¢¢hanica] connection, Site ewlBalion, scptic pgrmit, e]ectriea! <br />service or pIu~lhing water/~ewCt lines are ~oparate t~quimd permits. M(215-64 <br /> <br /> <br />