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MARION COUNTY BUILDING INSPECTION 'FOR OFFIC~E USE ONLY 22 ' ~oT~ ~ FOR OFFICE USE ONLY I Zoning Validatiol~_' d/~? 8:0O ~4~~ ~-~47 [Date:' ~ -'$J-q~ C~e-A~b~88-79~ '~ ~ F~794[EB 2 B lu- I Sid~- '' I m~iae: MANUFACTURED STRUC~RE COYOTE ALL SEC~ONS, 1 T~OUGH 4 PER~T APPLI~ ( ) Attached Commercial( ) New( ) Replacement( ) ( ) Detached Manufactumes Year of I Color of I Serial#: gg~/ ~/~.-0~-'~ Manufacture: /qb Approved Label: )~a--"l~ ~g Type of Siding: /~/~ , Type of Roofing: ff.~ ~%.4p' [ Sq. Footage: /..~ ~ ~) [ No. Bedrooms: 2. Location of Installation PmpertyOwner~g..~g_/~.q ~O./~t ] Mailing Address PhoneNo. ~- ~ JobAddmss ~ ~ ~ T~Acc~No. ~ ~.~ ~/ CrossSt~et~~~ Su~sion ~ I Bl~k Urban Growth Bounda~7 Se~on ~ To~s~p ~ Range~ ~e ~ Map Water Su~ly: L~ Wid~ ~/' ~ ~/p q Acres ~eg. ~t ~ Comer ~ Private Wen ( ) Sp~g Commu~ty WeU ( ) City 3. Contractor Information P~ope~y Owner }~t).4 ~;,~t t.~O~V I M~U~gAddre-- IPhone No' ( ) I own, reside in, or will reside in the completed structure. ( ) I understand that I must register as a construction contractor if the structure is sold or offered for sale before or upon completion. ( ) I will be my own general contractor. If I hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board. 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 immediately notify Marion County of the name of the contractor. ~,~'~_~/~t~-D .g.~. -X Contracr Business Name & #' t' /.~ ' ~ /~ Mailing Address' 6 0 Phone:_.~}... ( I~I am a registered builder OR the authorized representative of a registered builder. Authorized agent or leasee:/~& 4. Fee Schedule Mailing Address: --~)~ L-~'-- Phone: A. (1) (2) (3) Manufactured Home .gt./~, t~ or Modular Unit Placement/Connection @ ~ ~f/~ tr0 C. Additional Inspection State Fee @ 20.0O = ~]~J. F'O or Reinspection State Surcharge @ .L%0O¢& ~.- ]~ D. Investigation Fee Z~,dag Sui~,~,s~ (jfi. O0 if appnca~ fft~ ¢~ e_..-- TOTAL: $ .J/d/-0 E. Other inspections not listed @ $40.00 B. (1) Mfg.'d Structure Storage Fee @ 40.00 per hour (2 hour minimum) @ $ 25.0o =__ (2) Mfg.'d Structure Storage Renewal @ 25.00=__ TOTAL= (3) Zoning Sureha*ge O5.00 if appn~ble) @ 15.00 =__ ~c~rm': @ $60.00 =__ 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 on the reverse side of this form. ~. Name of Applicant (pleas~ L/f~ _I _~t~..~ Phone: 7~fi;~ 7~7 ~ Signature of Applicant: '~--~-~ ~~~- ~5C ¢ Date: ..;2--_/.~_j../ y~ This fee covers the manufactured structure placement, plumbing connection, electrical connection and mechanical connection. Site evaluation, septic permit, electrical service or plumbing water/sewer lines are separate required permits. MC 15-64 Rev 11-91