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FOR CITY V~LIDATION <br />Received By: ///4 <br />zoning Validation: <br />Date: ~-~S- ~, <br /> <br /> MARION COUNTY BUILDING INSPECTION FOR CITY USE ONLY <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 City Seth~l~ ~irements: <br /> <br /> 8:00ara-4:30pm Phone S88-S147 c'%% <br /> 24hr. I~pectlonLine$88-7904~' [';~'3~ l~Si,~-~ ~, ~ PdghtSid~ ! <br /> <br /> BUILDING PERMIT APPLIC~ <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />( )Addition ( )Relocation ( )Addition ~QNew <br />( )Al~mfion ( )~ ( )Al~rafion ( )Sign <br />(~)Accesso~ ( ) ~ange of Occup~ey ( ) O~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am the PROPRRTY O'~NER and own, r~ide i~, or w~ll reside M the completed structure and will be my own general conUactor. I understand that I must register as a construction <br /> ~ontractor if rite structure is sold or offered for sale before or upon compl~ion, ff I hire subconuactors, I will hire oaly subcontractors registered with th~ Consmlctlon ConUactors Bcanl, <br /> <br />I am an AUTHORIZED REPRESENTATIVR of the propeiW owner or contxactor. <br /> <br />R~gistrati°n~'~q qO <br /> <br /> S h~.,,e _ ,'ho= -I {,{ -7 7 q q. <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />VALUATION (See "Valuation Schedale" to determine valuation bes~d <br /> <br />on squa~ foetage of project.) Valu~ion: $ <br /> <br />B· Miscellaneous F~s <br /> (1) Additional Plan Reviews or Addendums <br /> <br /> (2) Investigation <br /> <br /> (3) Rehmpection Fee @ $25.00 <br /> <br /> (4) Other Inspections not listed almvc <br /> <br />=$ <br /> <br />TOTAL = $ <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />Name of Applicant (Ple~e Print): 1~ ~ I~ ~ [LIJ[ ~. Phone: <br /> <br />Sigaature of ^pplicant: [,?~1%'Jt~ .~t.~_- . Date: <br />MC 15-73 Rev 1/95 fl <br /> <br /> <br />