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FOR CI~T¥ VALIDATION MARION COUNTY BUILDING INSPECTION [ FOR CITY USE ONLY <br /> 285 Church St. NE - R~olB 132 [City SetbackRequi~ments: <br />[Re~ebred By: ~- COMMUNITY DEVELOPMENT CENTER <br /> <br />I <br /> <br /> BUILDING P~IT ~PPLIC~TION <br />COMP~TE ALL SECTIONS 1 THROUGH 4 <br /> <br />RESIDENTIAL COMMERCIAL ~ ')1~ ~t~ture: <br />( ) Addition ( ) Relocation ( ) Addition ( ) New <br />( ) Alteration ( ) Other ( ) Alteration ( ) Sign G ~ o.~ 9~ <br />~ Accessory ( ) Change of Occupancy ( ) Other <br />DesctiptionofWork ~ ~.~ I~... Isthisahistoficalbuildlilg? Yes - ~ <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> Maillng Address Phone <br /> <br /> ( ) I am an AUTHORIZ, ED REPRESENTATIVE of the property owner or contractor. <br /> Name <br /> <br /> Mailing Address Phone <br /> <br />4. FEE SCHEDULE <br /> <br /> A. <br /> Valuation: $ ~ <br /> <br />( 1 ) permit <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Structarai Plan Review (.65q~ x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />P. ECl~lt~r: __ kTGTAL = $ I4/~ ~ <br /> <br />I hereby certify that the above information is correct. <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 />NameofApplicant(PleasePrint): ~$'~//~,o/~/~ ~ ~/~/~t ~]t*PJ¢,")/t <br /> <br />MC 15-73 Rev 1195 <br /> <br /> <br />