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[~OR CITY VAI~'-~ MARION COUNTY BUILDING INSPECTION I FOR CITY USE ONLY <br /> ~ '~7-J~-Y-- - COMMUNITY DEVELOPMENT CENTER I <br /> R ~ived B '~ 285 Church St. NE - Room 132 City Setback Requkements: <br /> <br />[ZoningP'Validation: ~ ~:~/*2s r *~ [~ 'gffil~m-4.3Onm Phone 588-5147 [F~ont: ~ Rear: <br /> <br />/__ _ BUILDIN(lnl~I~dIT APPLICATION <br />COMPLETE ALL SECTIONS, 1 THROUGH g[~-2-~].I~g; ~ FiB 2 4 J999 <br /> <br /> MARION efl,!~rv <br />1. JOB DESCRIPTION m~trllU~/ COUNTer, <br /> P~SmSNm~ BUILo~ ~:qff ~A~~ BI Ir~'s_ ) .~/,~~ : ~.~, <br /> ( )Addition ( )Relocation () ition ()New <br /> ( ) Al~ration ( ) O~er ( ) Altera~on ( ) Sign <br /> ( ) Accesso~ ~ ~a~e of ~up~ ( ) O~ <br /> <br />~er~ Para: ] No. Sto~es / i ~o.o~o~,~: ~,~,. 7 Now- ~ I No. B~ms: <br /> <br />2. LOCATION OF INSTALLATION <br /> <br />Bleek <br /> <br />Water Supply: <br />Pllvat* Weil ( ) Spring <br />CommueityWeti ( ) City <br /> <br />3. CONTRACTOR INFORMATION -- PLEASE INDICATE WHO IS DOING THEWORK <br /> <br /> I ara thc PROPERTY OWNER and own, reside in, or will ~side in the completed stxucmrc and will be my own general contractor. I understand thai I must rcglater as a construction <br /> <br />4. FEE SCHEDULE <br /> <br />A. <br /> <br />(1) Permit Fee <br /> <br />(2) 5% State Surcharge (.05 x Al) <br /> <br />(3) Stmctttral Plan Review (.65% x Al) <br /> <br />(6) Seismic Surcharge <br /> <br />TOTAL <br /> <br />I hereby certify that the above information is correct. <br />Permits are non-transferrable and expire if work is not s~arted within 180 days of issuance or if work is suspended for 180 days. <br />Name of Applicant (Please Print)~ _Phone: <br /> -- J J ' <br />Signature of Applicant: Date: <br /> <br />MC 15-73 Rev 1/95 <br /> <br /> <br />