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FOR CITY VALIDATION <br />R~c~ive~i by: <br />Date: <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St NE · Room 132 PERMIT NO: <br />Salem, OR 97301 <br /> Date: <br /> <br /> 24 hr. Inspection Line 373-4427 <br />Office: Phone ,688-5147 8:00am - 4:30pm <br />FAX: S88-7948 <br /> <br /> PLUMBING PERMIT APPLICATION I <br /> I <br /> Please complete all Sections, I through 5 <br /> <br /> 1. LOCATION OF INSTALLATION <br /> <br />ci~ ~ O,P~oe~ <br /> <br />Propert~Owner ~tCkt~,~ L~..~O$~I Phone~ <br />Cross Stre~t/Dlrecdons: <br /> <br /> PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> I <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />I ,ob.o. <br /> <br />Contractor's Board R~g. No. <br /> <br />loumcyman's Plumb~a No. <br /> <br />Contractor's Signatur,: ~J/.~ ~~ <br /> J <br /> <br />2B. FOR O~R ~ST~LATIONS <br /> <br />Property Owner (please print) <br /> <br />3. PLAN REVIEW SECTION <br /> <br />Marion County does not require a plan review. <br />We will provide plan review service if you complete <br />Section 5B and submit two (2) sets of plans and <br />specifications with this application. <br /> <br />Issued by: <br /> <br />4. FEE SCHEDULE (Complete and enter total in Al below) <br /> <br /> RESIDElqTIAL ~ i FOMMERCIAL El <br /> USE OF STRUCTURB: /~-o,n.%, <br /> NEW El ALTERATION ~3 ADDITION ~] RELOCATION <br /> <br /> No. X F~o = Sum <br />BASE FEE ~ $20.00 <br /> <br />RESIDENTIAL (each fixtore) <br />Atm~ra Dwelling Plumbing Fee __ sq. fL x $,070 = <br /> <br />Single Family or multi-family per <br />dwelling unit <br />New construction $10.00 -- <br />Alterations $10.00 -- <br />Reconnect ! $ 5.00 ,~'o <br />Relocated Structure $ 5.00 -- <br />Modular Structure $ 5.00 -- <br /> <br />Water Lines <br />First 100 ft. or fraction thereof $20.00 -- <br />For ea. addnl' 10O ft. (up to <br />maximumof50o fl.) $15.00 -- <br /> <br />Sanitary & Storm Lines <br />First 100 fL or fraction thereof $30.00 -- <br />For addnl' 10O ft. (up to <br />maximum of S00 fi.) $15.00 -- <br /> <br />COMMERCIAL (each nxture) <br /> <br /> New ¢onsttucfton $10.0O -- <br /> Alterations $10.00 -- <br /> Reconnect $10.00 -- <br /> <br />Water Lines <br /> First 100 ft. or fraction thereof <br /> For ea. addnl' 100 ft. <br /> <br />$25.00 -- <br />$15.00 -- <br /> <br />$15.00 __ <br /> <br />PROTECTIVE BACKFLOW DEVICB <br />Lawn vacuum breaker (sprinkler system)__ $ 4.50 -- <br />All others $10.00 __ <br /> <br />OTHER Os reqnired by OSPSC <br /> and Build~ng O~ciM) <br /> <br />DWELLING PERMIT LABEL # of Labels N/C <br /> <br />5. FEES <br /> Al, Enter total of fees from Sec. fi4 <br /> A2, Add 5% surcharge (.05 x Al) <br /> Subtotal $ <br /> <br /> B. Eater 25,% of lin~ Al for PI~ Review <br /> (Al + .25), if ~qu~d $.__ <br /> C. lnwsfige~on Fee (Jf~qui~d) $___ <br /> D. Rei~peetinn Fee ($25.~) $___ <br /> <br /> Receipt No. <br /> <br /> <br />