Laserfiche WebLink
FOR CI~?Y vALIDATION I MARION COUNTY BUILDING INSPECTION ~ ~ <br /> " ' " ////,' ,"/ /~]~z ~ COMMUNITYDEVEL(~dIENTCENTER <br /> Received By: · (~f~r ~ff ~.~ ~-~eo7~ 285 Church St. NE/~ 132 2ity Setback R~u~n~: <br /> _ . · / ~4~ S~m,O~gJ~ ~ <br /> <br />COMPLETE ALL SEC~ONS. 1 ~ROUGH 4 ~ ~ ~. < 5' l~0 ~///~ <br /> ~/IV~ 1~.~ <br /> ',v6~ <br /> <br />i. job UESCmrrion <br /> <br />( ~'~ddition ( ) Relocation ( ) Addition ( <br />( ) Alteration ( ) Other ( ) Alteration ( ) Sign <br />( )Accessory ( )ChangnofOcctlpancy ( )Other <br />I~scfiption of Work <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE ENDICATE WHO IS DOING THE WORK <br /> <br />( ) I am the PROPERTY OWNER and own, r~ide ~n, or wRl r~sid~ in th~ comple~d stmcmm and will I~ my own genre-al ~onttactor. I understated that I must ggis~r as a comtmcfioa <br /> <br />(.~ [ am an AUTHORIZED REPRESENTATIVE of the property owner or conwactor. <br /> Mailing Address <br /> <br />4. FEE SCHEDULE <br /> <br />Ao <br /> <br />VALUATION (See "Valuation Schedule" to d~t~nlnc valuation based <br /> <br />on squar~ f~otage of Inoj~ct.) Valuation: <br /> <br />(~) ~t Fee <br />(2) 5% State Su~h~ (.05 x Al) <br />(3) S~c~ P~ Review (.65% x Al) <br />(4) ~re & Life S~ P]~ R~iew (.~% x Al) <br /> <br />(5) ~niug Surch=ge, ffapplicable (.~% x Al) ~ ~ <br />(6) Seismic Su~h~ <br /> <br />1 hereby certify that the above information is corcect. <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 /> <br />Signature of Applicant: / ) Date: <br /> <br />MC 15-73 Rev I~95 <br /> <br /> <br />