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c;mc <br />Received by: ~ <br /> <br />PLUMBI G P RMi APPLICATION <br /> <br /> 1, L~AT[ON OF iNhALaTION <br /> <br />City' C~s~ <br /> <br />Code-A-Phon~: 588-7904 <br /> ss- 48 Dat :UILDING NSp 77 <br /> <br />PEP. MITS ARE NON-TRANg~EP, ABLE AND NON-I~Fk'q, IDABLE AND <br />EXPIRJ~. IF WO~ IS NOT STARED ~ 180 DAYS OF ISSUAN~ <br />OR IF WOrK IS SUSPENDED FOR 180 DAYS. <br /> <br /> 2A- CO~CTOR INSTALLATION ONLY <br /> <br />M~illns Address <br />Prol~ay Owner '}' Phone <br />Plumbiug Board: <br /> <br />Job <br /> <br />Contntctofs Board ReS. No. <br />$oumeyman's Plumbers No. <br /> <br />Contractor's $ignatul~: <br /> <br /> :lB. FOR OWNEt~ INSTALLATIONS <br /> <br /> 3, PLAN REVIEW SECTION ~ <br /> <br />We will provide plan review service if you complete Section <br />5B and submit two (2) sets &plans and specifications with <br />this applieadon. <br /> <br />This optional plan review program does not suspend the <br />~'equired submission of plans, and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 53. <br /> <br />4C 15-¢5 <br />Rev. 7/92 <br /> <br /> Issued by: <br /> <br />4. FEE SCHEDULE (Complete and enter total in A1 below) <br /> [] P,~SIDENTIAL ~,~COM]vlERCIAL <br /> <br /> 'blEW [~ALTERATION [] ADDI]ION [] KBr,ocA'/IOlq [~ <br /> <br />BASE FEE <br />A, RESIDENTIAL <br /> <br /> Single Family or multi-Family per <br /> dwelling trait (each fixture) <br /> New construction <br /> Alterations <br /> Re-located structure <br /> <br /> Water Lines <br /> First 100 t~. or fraction thereof <br /> For additional 100 fl. (up to <br /> maximum of 500 feet) <br /> <br /> Sewer Lines <br /> First 100 feet or fraction thereef <br /> For a. dditi0nal 100 feet (up to <br /> maxnnum 500 feet) <br /> <br />B. COMMERCIAL (each fixture) <br /> <br /> New constmcti6n <br /> Alterations <br /> Re-locate~ st, mcture <br /> <br /> Water Lines <br /> First 100 feet or fraction thereof <br /> For additional 1 O0 feet <br /> <br /> Sewer Lines <br /> First I00 feet or fraction thereof <br /> For additional 100 feet <br /> <br /> LAWN SPR/NKLER. SYSTEM <br /> Each protective baekflow device <br /> <br /> OTHER (as regu, ired by OSPSC and <br /> Building Offictal) - <br /> <br />NO, XFEE =SUM <br /> <br /> $20,00 <br /> <br />--$ 9,00 ~ <br />--$ 9.00 .... <br />__$4.50 , <br /> <br />. $2O.00__ <br /> <br />$15.00 ,. <br /> <br />- $15,01Z., <br /> <br />9,00_ <br /> <br />~$20.00 <br /> $15,00 ,- <br /> <br />~$30.00 <br />__$15.00, <br /> <br />...... $ 4.50 <br /> <br />5. FEES Al. Enter total of fees from Sec. # 4 <br /> A2. Acld 5% surcharge (.05 x Al) <br /> <br /> Subtotal <br />B, Enter 25% of line Al tbr plan Review <br /> (.25 x Al) if required <br /> C. Investigation Fcc(if required) <br /> D, Rcinspection Fee <br /> <br /> TO]AL AMOUNT DUE <br /> <br /> <br />