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FOR OFFICE ,USE ONLY <br /> <br /> - 4;~,~ pm <br />C. ode.A-Ph oae <br /> FAX <br /> <br /> MARION <br />BUILDING iN,SPEf;,JI/ N <br /> <br /> Corox0 'o,'' - aiZe Flow'~ ' <br /> <br />~$~dord s~lem mo~ t~z~ 1000 ~. DS~; <br />HcIdin~ Ta~ ....... 2~$.~ : i0.00 <br />Scep~ ~nch 24~.~ .... r 10,00 <br />Pla~ ~vlew <br />$~ration~ 245_o0,,. J ~ 10.00 <br />~ep~ir, Mi~0t 75.00 ; 10 00 <br />Annual Bva uati0a ~f~e S s~m : ig OO <br /> <br />( ) I ~il{ ~a{{ when Tc~ Holes D.g ' <br /> <br /> ) I am pocosin8 wo~ ou ~ p~pe.y I o~ or ocoup~ <br /> ) l am a r~sJsze~ed buJldcr o'r ( ) tho {uihod~d ~en~ive · <br />~) ~c wor~ will ~ pe~o~d by · D~ ~ic~n~d In,miler <br /> <br /> ~qmflv <br /> S;m ~alua~, ea. ~dL ~ 20~,00 20,~ <br /> ~ssu~ Disin%Ufioa ,,3~0.~ 10,~ <br /> Redundant :, , ~ 00. 10.~ <br /> <br />.~eeo Stone ~ 245.~ ~0-~ <br />~p~{mctio,n pe~t ~¢wal ~o Field Visit) 85,00 10,~ . <br />=.Autbofizaticu N~ ~ F~ld Vlsi8 8f0,~, I0.00 <br />~I A~a V~ance ~te ~aJu~o~ 24~,~ 20.00 ,,,, I <br /> <br />MC 15-SI 'REV ~3 <br /> <br /> <br />