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FzoOR'CITy Y A, LIOA/TION I <br />ecei,~eff By: ~d~:K_.I <br />ning Validation: ' ~ ~---~-ff---~ I <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br />1. JOB DESCRIPTION <br /> <br /> RESIDENTIAL <br /> ( ) Addition ( ) Reloc~on <br /> ( ) Alteration ( ) Other <br /> <br />__ ~l,A ~l , 0~' <br /> <br />COMMERCIAL <br /> ) Addition <br /> <br /> ) Alteration <br /> <br /> ) Change of Occupancy <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St. NE - Room 132 _.~.~ ~-.-~ <br /> <br /> (~New <br /> <br /> ( ) O~er <br /> <br />FOR CIT~Y ~ <br /> <br />New - <br /> <br />2. LOCATION OF INSTALLATION <br /> <br /> Prop~y Ovn~r <br /> <br />Subdivision <br /> <br />Mobi~ Home Park <br /> <br />Lot Bl~ck <br /> <br />Water Supply: <br />Private Well ( ) Spriag <br />Community Well ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> () <br /> <br /> () <br /> <br />() <br /> <br />4. FEE SCHEDULE <br /> <br />B. Miscellaneous Fees <br /> (1) Additional Plan Reviews or Addendums <br /> (2) Investigafon Fee <br /> (3) Reinspection Fee @ $25.00 <br /> <br /> (4) Olher Inspeetioas not listed above <br />RECEIPT: ~ <br /> <br />TOTAL <br /> <br />=$ <br /> <br />Name of Applicant (Please Print): <br /> <br />Signatere of Applicaut: <br /> <br />MC 15-73 Rev 1/95 <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not s~arted within 180 days of issuance or if work is suspended for 180 days. <br /> <br /> Phone: <br /> <br /> Date: ~ <br /> <br /> <br />