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FOR OFFiCE~J~ .E pNLy MARION COUNTY BUILDING INSPECTION FOR OFFICE USE ONLY_ <br />~ , ' _ ~ . -~77'///~4=4n~--~- 220 High Stl~eet NE Cit,, Set~ack <br /> <br />1. Job ~flp~on <br /> <br /> ( ) ( <br /> ( ~New S~gle F~y Dwell~g w/o g~e ( ) G~e, <br /> <br />Tras* ( ) or R~ffl~t ( ~ [ NO, Stories ~.~ l Detached <br /> <br />No, D~oo~: J <br /> <br />2. Location of Installation <br /> <br />Mo~l~ Hom~ P~R S~ ~ <br />L~Wid& W~' ~De~ [~/ A~s ~eg.~t ~,r ~ Commu~tyW~,l( ) City <br /> <br />3. Contractor Infornmtion <br /> <br /> iii V ~ I own, r~id~ in, c~ will r~ide in the completed ~a'uctur~, . <br /> <br /> understand t~at I m~mt ~s~r ~ a ~ ~n~ ff ~e ~a~ is sold or.off~ for sale ~f~e o~ u~n <br /> will ~ my own general <br /> <br />If I hire subcontractors, I will ~ only subeoatraet~ registered wi~h the Coustmetion C~tractor~ B~ard, If I ehauge my mind and do hire a general <br /> <br />( ) I am a registered builder OR the enthotlzed representative of a t~glstered builder, <br /> <br />[ Phon~: <br /> <br />Ar¢ltiteet n~me: I M~nng Addregs: [ Phone: <br /> <br />4. Fee Schedule <br /> <br />A, New One-and-Two Family Dwelling C~de <br /> (inload~ ~1, Me, PI) <br /> <br />(1) GrossSq. l~. [ I'"~ f) x$-28 <br /> <br />(2) 5% State Surcharge (,05 x Al) <br /> <br />(3) Phm Review <br /> <br />(4) Zoning Surcharge ($15 if applicable) <br /> <br />= $185.00 <br /> <br />MJseell~ec~ Fee~ <br /> <br />(1) Dfivew,/y w/eulb ~ $7.50 <br /> <br />~) ~veway w/o ~ ~ $17.~ <br /> <br />(3) Additional ~an Reviews or ~dendu~ <br />(4) Inv~gafi~ F~ <br /> <br />(5) R~in~cto~ F~ ~ $25-~ <br />(6) ~ Ius~fi~ not lis~d ~ <br /> <br />TOTAL <br /> <br />revers~ sJdo of this form, <br />Name o£Applicant (Plea~ePrint): ~S./Z~/~ /~ /% ?~e~ ~onv: _~7.Y- ~2 ~ O <br /> <br /> Sit~ ~valuafions and septic work ~q~rat~ ~, ~eck wi~ M~Jon County B~lding l~ion ~fo~ sub~tfing ~s ~pllcafion. <br /> <br /> <br />