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FOR OF[.ICJg USF.-ONLY[ MARION COUNTY BUILDING INS~~. "~f:-/~/"~' <br /> :220 High Su~t ~ ~OR OFFICE USE ONLY <br />Received by: ~ ~ S~em:; OR 97301: ~ ~ ~ l~l~ Setback <br /> Validatiog~fi gmm4:g~Sgg~147 ~O O I~ *" t. , <br /> <br /> MANUfACTUReD STRUCTURE ~Z~22-Z._ <br /> PER~APPLICATI~L~8-1N~P~GTION <br /> CO~Tg ALL SaC~ONS, ] T~ouan 4 <br /> <br /> 1. Job D~cfipfiofl <br /> <br />:2. Locationoflnsudlation ', /~a~'.fdZ//Z-. ~i;7d'~5- <br /> <br /> ; ' '" ' ' 'L~ : BI~ Uthafi G~wth Bounda~7 <br /> <br />Acm, ~eg.~;~g ~mer ~0 PfivamWell ( ) Spring <br />:: : Commu~tyW~l ( ) City <br /> <br />3, Contractor Information <br /> <br />( ) I own, ~cside in, or will reside in thc compietcd structure. : , : <br /> <br />( ) I understand that I musi register as a constractien connector ff thc stmcmm is sold or offered for sale before or upon eernpletlon. <br /> <br />( ) I will be my own gtmeral contractor, . , <br /> <br />If I him subcontractors, I will hire only subcontractors registered 'oAth the Constmctkm Contractors Beard. <br />~ I change my mhd anddo hire a general contractor. I will connect With a contractor who is registered with the Construction Contractor's Board, and will <br />immediately noffy Marion Comfy of th* namo of the cOfitraO, br. : qge~/-/O <br /> <br />( t~ I am a regis~fed builder OR the authorized representative of a ragisterext builder. <br /> <br />4. Fee Schedule ', :: <br /> <br />A, (1) ManufactumdHome <br /> <br /> or Modular Unit PlacemlmffConnection @ <br /> (2)' State Fee A,L l~ 20.00 = ::'i <br /> O) State Surcharge <br /> <br />C, Additional Inspection <br />· , otRemspecuon <br /> <br />D. kavestigation ,Fee <br /> <br /> ~ ~-'~-'~ TOTAL: <br />(1) Mfg/ol Stru~tut~ Storage Fee <br />(2) ~g.'d S~ctum Storage Renewal ~ 25~ = <br />(3) ~t~g $u~e ( 15,~ if a~hcable) ~ 15,~= <br /> <br />E. Other inspections not listed <br /> @ 40.00 per hour (2 hour minimmn) <br /> <br /> @ $40.00 =__ <br /> <br />*IDTAL = $~,~..~9 <br />RECEII~I': ~ <br /> <br />I hereby certify that the above information Js correct and that I have lead ind understand the Information Notice lo Property Owners about Construction Respon~ibklJtie* <br /> <br />slg,,a,ur o, Ap.,,c.n,, <br /> / / <br /> <br />service or plumbing water/sewer lines are separate required permits. MC 15-64 Rev 1 ] -91 <br /> <br /> <br />