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FOR CITY VALIDATION I MARION COLqqTY BUIL,I~ING INSPECTION FOR CITY USE ONLY <br /> ..a ~, /~ / COMMUNITY DEVELOI?'a~IN~CENTER <br />Rec. eived Wv: ~ 28 $ Church St- NE ~t/l(~l~?..-.. City SeOa~k l~iulmmm: <br /> <br /> ulN , CO <br /> <br />1. JOB DESCRIPTION '"~ 11~'~/? <br /> ( ~fion ( ) Rel~afion ( ) Addition ( ) New <br /> ( ) Alteration ( ) O~er ( ) Altera~on ( ) Sign <br /> ( )Accesso~ ( )ChangeofOccu~ey ( )O~er <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> ( ) I am thc PROPERTY OWNER and own, reside in, or will r~side in the compl~tnd stracmre and will be my own general con~, I undemand that I ~ust ~i~.ec a~ a conaav~tioa <br /> contractor if the structure is sold or offend for sale before or upon compled on. If 1 him subcontractors, I will hire only subcontractors registered with the Construction Coauactora Board. <br /> <br />( ~"~"~ I am an AUTHORIZE~ R~PRESENTATIVg of the p~oporty owner or contractor. <br /> <br />4. FEE SCHEDULE <br /> <br />VALUATION (See "Valuation Schedule" to d~tmin¢ valuation ba~d <br /> <br />on square footage of project.) Valuation: $ <br /> <br />(2) 5% State Surcharge (.05 x Al) = <br />(3) Sffuctural plan Review (.65% x Al) <br /> <br />RECEIPT: ~t~ 7 <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-frans fercable and expire if work is not started within 180 days of issuance or if work is suspended for 180 days. <br />Name o£ Applicant (PI~ f~...~ % ,or.,; <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />