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MARION COUNTY BUILDING INSPECTION [ FOR OFFICE US.E ONLY <br />220 High Street N~ L~y.ICity Setback Requirements: <br /> <br /> FAX 588-794~ '~ ..... ,~ ' <br /> BUILDING pERM1TAPPLI(~'v~I(~i~ ~VV,~ <br /> <br />CO a, LEr SSCZ OSS, 1 HROUOH 4 ttION <br />L Job Description !LOINQ INS?EOliON <br /> <br />RESIDEN'I~L COiVlMERCIAL ( )New i Use of Structure; <br />()Addition ()Relocation ()Addition ()Sign ~g)/g ~t/~/l~ <br />( ) ~mol{~ ( ) ~t~ratinn ( ) Domoliti~ <br />(~cesaoW ( )~ar ( )~angeofOccupanvy ( )O~er , . <br /> <br />2. Location of Installation <br /> <br />Subdivision Lot Bt~k <br />Mob~c Home Park S~ace ~ <br />LotWid~ /~i rog Depth ~ Z Aerii .......... I~cg,~t fie Comer '~O PdwtteWe]t () Spring (> <br /> <br /> .................................. Community Well ( ) City,,,,,,,~,,,) <br /> <br />3. Contractor Information <br /> <br /> ( ) I own, reside in, or will reside in tim completed <br /> <br /> (~'I will be my own general contractor <br /> <br /> :ontraemr Business name & #: ] Maillng Address: [ Phone: <br /> ( ) I am a registered builder OR the authorlzed mprosentailve of a registered builder, <br />Architectname: ~ ~O~L "~- ~-Z t'~'~O [MaillngAddress: [Phone: <br /> <br />4. Fee Schedule <br /> <br />A. VALUATION (See "Valuation Schedule" <br />to determln¢ valuation based on <br />square footage.) Valuation: <br />(1) Permit Fe~ <br />(2) 5 ~ State Surcharge ( 05 x A 1) <br />(3) Sm~ctural l'lan Rcvicw (,65% x A1) = <br />(4) Fire & Life Sai~ty I lan Review (.40% x Al) = <br /> <br />(1) Driveway w/curb Ca) $%50 = __ <br />(2) D dveway w/o curb @ $17.(X) = __ <br />(3) Site Plan Review (commercial only) @ $79.00 = . <br />(4) Additional Plan Reviews or Addendums = __ <br />(5) Investigation Fee = __ <br />(6) Reinapeetiou Fee @ $25.00 ~ ............ <br />(7) Odl,~/InSpeCti(~S riot [isI¢d above <br /> <br />I hereby certify that the above information is correct and that I have read and understand the Information Notice to Property Owners about Conslructivn Responsibilities on the <br />reverse side ~f this form, <br /> <br /> / <br /> Site evaluations, septic, electrical, plumbing and mechanical work require separate permits, Check wilh Marion Co0nly Building Inspe~ion before qubmi,ti~g this application, <br /> <br />MC 15-73 Rev. 11/91 <br /> <br /> <br />