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FOR OFFICE USE ONLY <br /> <br />Code-A-Phone 588.7904 <br /> <br /> DWELLING/STRUCTURAL <br />COMPLETE ALL SECTIONS, i THROUGH 4 <br />1. Job Description <br /> <br /> ~O~ OFFICE USE ONLY <br /> <br /> Loft Side I Ri0ht Side <br /> FAX 588-7948 MARIR~I~_~,Cl~ LI AT ON <br />AND/OR SEe~l~.mm~P C '- "'" u~SPECTION <br /> <br />RESIDENTIAL COMMERCIAL <br />[ ] NewSFD',Wgarage [ ] Accessory [ ] New ~ Sign <br />[ ] Ne~ SliI)',~/ogarage [ ] Relocat~ [ I Adthnon '[ ] Demo <br />[ ] Addition [ ] Demo [ ] Alteration [ ] Other <br />[ ]Alteration [ J Other [ ] Change/Occupancy <br /> <br />;se o£ Building:: GAS STAT I ON <br />~o Storie*:: 1 I B~emc'nt:: Y[]N[I IOm:; lqoo, Area;; I lI~'ght:: I Occupa"t Load <br /> <br />2. Location of Installation <br /> <br />Job Addre~J~ 12334 EHLEN R"D. Tax Acm No (:ross Street <br />AURORA, 0~. ~7002 <br />~ubdt~ l~[on Lot Block <br />~bi1¢ llomc Park Spa~ ~ <br /> <br />section .... Townshl~ Ran'~c /~ne MAp Water Supply <br />LotWld~ ~tDepfl~ Acm~ l~g, Lo[ Comer ~' PfivatcWell [ ] Spring [ ] <br /> ~00~ 2~0~ XXZ C~m~ll~Wc]] [ ] Cti~ [ I <br /> <br /> Contractor Information <br /> <br />Propcr~yOwncr./ Mailm Add ~ on <br /> LEATHERS OIL 22300 [3E ~:[~,~ ~P:¥i'°L2~ <br /> <br />Auth Agcntfl~asee Mailing Addrexs & Phone No <br /> Name& Numbcr~ Marling Address & Phone No <br /> <br />4. Septic Information (Check where applicable) <br /> <br /> 'l'.sl I Ioles Ready ~] Will Call When Test Holes Ready [] <br /> <br />[l~m a registered bo~der OR [ J the. authori~,m-d representative of a regictered <br /> <br /> I '['he work w~ll I:~ perfommd b5 a regi¢mred builder <br /> Other__ <br /> <br />[ I I agree to build acoordmg tg~e submitted plans and spccificaJ~ns..,the laws of <br /> <br />5. Fee Schedules <br /> <br />A, New One-and-Two Family Dwelling Code Yaluatlon: $ ....... <br /> (mcludc~ El, Me., FI.) <br /> <br />(l)Sq Ft __. x ,28 <br />(2) 5% State Surcharge (05 x Al) <br />(3) Base Fee for Plar~ Review <br />(4) Zoning Surcharge (If Applicable) <br /> <br />8ublota[:: $ .... <br /> <br />135.00 <br /> <br />C <br /> <br />(1) Permit Fee <br />¢2) 5% State Surcharge (05 x BI) <br />(3) ~onmg Surcharge ( 05 x B 1 ) <br />(4) Plans Check (05 x Bi) <br /> <br />Septic Fees (Includes DBQ Surcharge) <br />(I) Si~ Evaluation <br />(2) New Septic l~$tallatico Pcmfit <br />O) Authotizalton Notice <br />(4) Existing System Report <br />(5) MalOr Repair <br /> Minor Reptdr (tank o~lly) <br /> <br />Valuation;; <br /> <br />8ubtotah $__ __ <br /> <br />(1) Driveway w/curb@ $7,50 <br />(2) Driveway w/o curb @ $17,00 <br />(3) Site Plan Review (commercial only) <br /> <br />(5) Reiflsp~t[~ Fcc ~ $2500 <br />(6) O~er m~tions <br /> <br /> x $40 <br />Total;: <br /> <br />Recelpt: <br /> <br /> <br />