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vba, omc Jsz oj,mY[ <br /> <br /> PLUMBING PERMIT APPLICATION <br /> P/ease complete all Sections, 1 through <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />M~RIOI~ COUNTY BUILDING 1NSPEC.TION., <br /> <br />220 ttigh S~ceet NE <br />Salem, Oregon 97301 <br /> <br />Phone 555-$147 8:00 a.m. ~ 4:30 p-m. SITE#: <br />Cod¢-A-Phone: 558-7904 <br />FAX: 588-7948 Date; <br /> <br />Dir¢~ions <br /> <br />PEILMIT$ ARE NON-TRANSIrtPRA. BLE AND NON-REFUNDABLE AND <br />EXpitLE IF WORK. I$ NOT STARTED WITHIN ltl0 DAYS OF ISSUANCE <br />OR,IF WOP, K IS SUSPENDI~D FOR 180 DAYS. <br /> <br /> 2A. CONTRACTOR INSTALLATION ONLY <br /> ldd/t,' [ <br />Mailing Address Mit/ <br />Properly ~ner [ Phone <br /> <br />No. <br /> <br />Plumbing Bo,'xd: <br /> <br />FOR OWNER INSTALLATIONS <br /> <br />Owner <br /> <br />Mailing Address Phone <br /> <br />CityLStat~/Zip <br /> <br />s, PLAN REVIEW SECTION <br /> <br />We, will provide plan review ~¢rvice if you complete Section <br />5B and submit two (2) sets of plans and specifications with <br />this application. <br /> <br />This optional plan review program does not suspend the, <br />required submission of plans, and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 53. <br /> <br />dC I§-4~ <br />Rev. 7/92 <br /> <br />4. FEE SCHEDULE (Complete and ca. total ia A1 b~low) <br /> [~ RESIDENTIAL [_~'COMMERCIAL <br /> US~ OF STRU.Crm~.; [] <br /> NEW ~TI~RATION [] ADDITION [] It~LOCATIOlq [~] <br /> <br />NO, X FEE -- SUM <br /> <br />BASE FEE <br />A. ILESIDENTL~L <br /> <br /> Single Family or multi-Family per <br /> dwelling unit (each fixture) <br /> Hew eonstn~mion <br /> Alterations <br /> Redocated structure <br /> <br /> Water Lines <br /> First I00 ft. or fractiou thereof --.$20.00 .... <br /> For additional 100 fl. (up to <br /> maximum of S00 feet) .$15.00~ <br /> <br /> Sewer Lines <br /> First 100 feet or fraction thereof __.$30.00.. <br /> For additional 100 feet (up to <br /> maximum 500 feet) --. $15.00 <br /> <br />B. COMMERCIAL (each fixture) · <br /> <br /> New constmeti6n $ 9.00 _ <br /> Alterations --.$ 9.00 <br /> Re-located structure $ 9.00__ <br /> <br /> Water Lines <br /> First 100 feet or fraction thereof <br /> For additional 100 feet <br /> <br />--.5 9.00-- <br />--.$ 9.00-- <br /> ,$ 4,50~ <br /> <br />--$ 4.50.., <br /> <br />I? $'d <br /> <br />is. FEES <br />Al. Enter total of fees from Sec. # 4 <br />A2. A~lfl 5% suscharge (.05 x Al) $ <br /> <br /> Subtotal $ <br /> Enter 25% of line A1 for Plan R,view <br /> (.25 x Al) if required ., $ <br /> <br /> D. Reinspection l:ee <br /> TOTAL AMOUNT DUE $ <br /> Re~olpt No. <br /> <br />C. LAWN SPRINKLER SYS "TEM <br /> Each protective backflow device <br /> <br />D. OTHER (as re§uired by OSPSC and <br /> Building Offieml) <br /> <br />First 100 feet er ffadion thereof <br />For additional I00 feet '/7<:kO~15.00 '-2/,L~ t <br /> <br /> <br />