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COMPLETE ALL SECTIONS, 1 TI.~OUGH 4 <br /> <br />L Job Description <br /> <br /> RE$1DENTIA][, COMMERCIAL ( )New Use of Structure: <br /> ( ) Addition ( )Relooatlon ( )Addition ( )Cig, -~"~--0 J"~/'~i '~ E <br /> ( ) Alu~ration ( )D~molititm ( )Al~t~on ( )D~nolitic¢l <br /> Description of Work: <br />, 'i~S!? ) or Rafter( ) [ Nc. Stories [ IOceupant Load..~[~umb~rofEmployees No, Bedrooms,, <br /> <br />2, LocationofInctallation fi,~Lc~'~ O~ q7.q~6 <br /> <br />1obAddmsa .~ ~ ~ ~ T~Acct, No, 90~]0 C~ssStme~ <br />Mo~e Ilom~ Pa~ S~ce 0 <br /> Private Well ( ) ~p~g ~"' ' <br />LmWjd~ ,~'c~ ' L~p~ /~e> / Ac~s ~eg.~t Comer C~mu~tyW~( ) City <br /> <br />3. Contractor Information ~g/4~ ~ <br />~mside ~, m ~ reside ~ ~ completed stratum. ¢2 J~ ~ <br /> <br />If I bh'e subcontractors. I wL!l bite ooly subcontractors rcgister~ with the Construction Contractors Bo~td, Lf I change my mind and do hire a general cot~traoot, I will <br /> <br />with a contractor who is mglstemd wlthe Construct[on Contra@toes Beard, and will immedlaml¥ notify Marion County of the name of the contractor. <br /> <br /> ( ) IamamgismmdbuflderOR~eau~ofi~drepms~fiveoft~gis~mdb~. O~ ~7~.~ <br />Architect name ~ Ma~g Address Phone <br /> ~ 7 <br />4. Fee Schedule <br /> <br />A. VALUATION (See "Valuabon Schedule" <br /> <br /> (1) Pcrmit Fee <br /> <br /> (2) 5% State Surcharge (,05 x Al) <br /> <br /> (3) Structural Plan Review (,65% x A 1 ) <br /> <br /> (4) Fire & Life Safety Plan Review (.40% x Al) <br /> <br /> B. Miscellaneous Fees <br /> <br /> Valoation: $ ~ OD (i) Driveway w/curb @ $7,50 = __ <br /> (2) Driveway w/o curb @ $17,00 = __ <br /> <br /> '~. ~--'O (3) Site Plan Review (commercial, on/y) @ $79.00 = __ <br /> ] * ~ ~ (4) Additional Plan Review~ or Addendums <br /> <br /> (6) Reinsp¢ction Fee @ $25,00 .,~O~ <br /> (5) ?x>nthg Surcharge. if applicable (.05% x A 1) (7) Other ~,pection$ not l~sted above ~t t ~. O O <br /> KECEIP'r:~ 'lO'i Xl, $ <br /> <br />i hereby certify that the above information is con'@ct and dial I have teed and undets~nd the Information Notice m Property Owners about Construction Re~ponsibllhies on the <br />reverse :i de of th $ form. <br /> <br /> Siteavaluadena,,ap~c, clectrlcal, plullbth;~¢;ha;icalworkmqulraxcparateparmits. Cheek with Marion County Buitdln8 luspectton before ,ubmtitiag ,;is applicat,on. <br />MC t5-73 Rev. 11/91 <br /> <br /> <br />