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[ FOR CITY VALIDATION <br />Rgeiv-edBy: ~ <br />Zoning Valid~ation: ~ <br /> <br />MARIONSOM~uUNN~TYDEBvUEtI~o~DMEINN~Gc INENTESRPECTION FOR CITY USE ONLY <br /> 285 C hutch S t.~.NFl~.~9oi.~ ~1~ 5-} ~ ~-i~ ~i;'~ ~ Clty Setback R~qulmment s: <br /> <br /> P~FABRICATED S~~ <br /> PE~IT APPLI~ C0~N~ <br /> <br />1. JOB DESCRIPTION BUILI]IN~ INSPECTION <br /> <br /> RESIDENTIAL COMMERCIAL USE OF STRUCTURE <br /> <br /> ( ) Alteration Iteration <br /> ()Addition ()Addition O~. <br /> <br />SquareFootege- lstPIoor: ~/~O$/~~12nd oo,: ~o~.~ I°thor: <br />Building Type - ~ Component Building: Sandwich Panel: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />~t Wide: gq I ~,~p~: /ZF I Acres: Im~,: C~r: <br /> <br />U~ ~wth Boun~? ( ) Yes ~ No Water Supply: ( ) ~vate Well ( ) Communi~ Well ~) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THE WORK <br /> <br /> I am an AUTHORIZED RRPRESEgqTATIVE of the propegy owner or the contractor. <br /> <br /> Name: (please print) <br /> Mailing Address: Phone: <br /> <br />4. FEE SCHEDULE <br /> <br />A. VALUATION (See valualior~ sehlx~ll~ tO d~t~r~ine ~$ ff~-d <br /> valuation based on square footage of l~oject.)~ <br /> <br /> (2) 5% Slat~ Surcharg~ (5% of Al) = ~ <br /> (3) Structural Plan Review (.65% of Al ) = *~' - ~'/~ <br /> (,) ri~ ~? s~j21h? ~ ~i~ (.4*~ o~ Al) <br /> (5) Zzr. LT~'~: "-'Z' :~ °?~icabl~0~m~qel) =~ '~1~ <br /> (6) Seismic Surcharge /'~ ~ ' <br /> <br />MISCELLANEOUS FEES <br /> <br />(I) Addifioual Plan Review ($40 per hour) ~ $_ <br />(2) Reinspecfion Fee ($25.00) = $_ <br />(3) Othe4~ inspections [$40/HR) = $ <br /> <br />TOTAL = $ <br /> <br />I hereby certify that the above information is correct. Permits are non-transferrable and expire if work is not started within 180 days of issuance <br />or if work is suspended for 180 days. <br />NAMEOFAPPLICANT(plrascpdm): ~4/~'t~,r~ fl~ ~r~? PHONE: ,~'~fi/2~;~ <br /> <br />MC 15~)5 Rev 3/95 <br /> <br /> <br />