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[R.eeF O~CITY' VALID ATION[ MARION COUNTY <br /> <br />COMPLETE ALL SECTIONS, 1 THROUGH 4 <br /> <br />1. JOB DESCRIPTION <br /> <br />RESIDENTIAL COMMERCIAL <br />(~ddltion ( )Relocation ( )Addition ( )New <br />( ) Alteration ( ) Other ( ) AReration ( ) Sign <br />( )Accessory ( )GhangeofOccupancy ( )Other <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br />4. FEE SCHEDULE <br />A. <br /> <br />on square footage of pr0ject.) Valuation: $ ~.~OO <br /> <br />(1) Permit Fee <br /> <br />(2) $% Stale Surcharg~ (.OS x Al) <br /> <br />(3) S~ral ~an Review (.65% x Al) <br /> <br />(5) ~ng Samh~ge. if a~licable (.05% <br /> <br />(6) Seis~c Sum~ge <br /> <br />I hereby certify that the ahoy* inforra~tion is cofrec~. <br /> <br />Permits are non-transferrable and expir~ if work is not stated within 1 BO days of issuance or if work is sgspend~d for 180 days. <br /> <br />Signatu. of AppXican,: ~ - Date: <br />MC 15-73 Rev 1/95 <br /> <br />=$ <br /> <br />-$7(, <br /> <br /> <br />