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ple~e co~lete ~ Se~ns, I through $ · [ <br /> <br />WOR~ I$ SUSPF~,NDED FO~ 180 <br /> <br /> CONTRACTOR. INFORMA'flON <br /> <br /> Oct o2_ <br /> <br />5u~i~ L~ No: <br /> <br />Ci~: S~; Zip: <br /> <br />~mucture t~ *old or affixal for ~le before or ~on <br /> <br />Owner's Signaeare: <br /> <br />3, PLaN REVIEW SECTION <br /> <br />$ ~.00 = S 2 <br /> <br />~. Sel~lc~ or F~ (Doff nol bclude bm~ ~n~ ~ ~m D) <br /> ~ ~OL or <br /> <br />~ Tem~ <br /> <br /> [ M~Baaeo~ (~ ~ F~ No~ Iadudea) <br /> <br /> ~m~m z S 5~.~ ~ S 2 <br /> <br />x S 65.00 = $ 2 <br />x $ 80.00 - $ 2 <br />x $ t30.00- S 2 <br />x S170,00 = $,, 2 <br />x $390.g0 = S 2 <br />x. $ $5.00 ~ S 2 <br /> <br />S 50.~0 = ~, ~' <br />$ 3.00 = S <br /> <br />TOTAL <br /> <br />5+ FEES <br />Al. Enter To'mi Pee~ from Section 0/4 <br />.62 Add ~ Su~hat~ (.05% x Al) <br /> <br /> s 5-$.'""- <br />SUBTOTAL: <br /> <br /> $62.50/N-. miaJmmn two bouts) <br />H, rmdu~ial Plant ($62.50tlmur) <br /> <br />TOTAL AMOUNT DU]~ <br /> <br />MC I $-34 Rev 9/9g <br /> <br /> <br />