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]FOR CITY VALIDATIONI <br />Ree. cived by: ,., <br />Dato: ,,, <br /> <br /> MARION COUNTY <br />· ' ' BUILDING INSPECTION DIVISION <br /> 3150 L~NCASTER DR NE - SUITE C <br /> SALEM OREGON 97305-1398 <br /> <br /> 24 hr. lnspectlott Line 373-4427 <br /> <br />PERM~ NO: <br /> <br />Data: <br /> <br />PERM[TS ARE NON-TRANSFERABLE AND EXPIRE IF WORK 18 NOT <br /> STARTED wrrnlN 180 DAYS OF ISSUANCIi OR/F <br /> I <br /> WORK IS SUSPENDED FOR 1~0 DAYS, <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Cemr~ctor's Licease No, <br /> <br />2B. FOR OWI'CttK INSTALLATIONS <br /> <br />Fmpcrry Owner <br /> <br />City/SUite/Zip <br /> <br />Owner's Signam~: <br /> <br />Agent's Siglmlure: <br /> <br />,rr~ GAS ~ or ELE~JI'KIC <br /> No. X <br />icl 01tA <br /> FORCI/D AlE FURNACE <br /> over 100,000 BTU <br /> <br /> Floor Fumaee <br /> Suspended Heater <br /> Wall iI~am- <br /> l~]or Mouhted Heater <br /> <br /> It]EAT POMP <br /> under 3 Ton <br /> 3 Ton and up <br /> <br /> AIR COI~ITIOI~ER <br /> under 3 Ton <br /> 3 Ton and up <br /> <br /> EvaporativeCeolcr <br /> Commercial Exhaust System <br /> <br /> Domestic Range Hood <br /> <br /> Commemial / Industrial Incinerator <br /> <br /> O~s L~S IAght~r <br /> Oa~ aad~qu~ <br /> <br /> GAS PIPING -~YSTBM <br /> 1-4 outlets (~or outlel) <br /> 4 end up outlets (per <br /> <br /> m app/ianco pormlt <br /> <br /> OTNER (~ ~ui, z8 ~ ~u~l~ 08i~iM) <br /> <br />$10.00 <br /> <br />$6.00 <br />$ <br /> <br />$ G.O0 <br />$ ~00 <br />$ 6.00 <br />$ §.00 <br /> <br />$ 6.50 <br />$11~0 ,, <br /> <br />$4.5O <br />$4.50 <br />$4,50 <br />$4.5O <br /> <br />$3.OO <br />$ 3.00 <br />$ 7.50 <br />$ 7,50 <br /> <br />$ 7,50 <br />$ 7,50 <br />$7.50 <br />$7.50 <br /> <br />2.00 <br /> .50 <br /> <br />$ 3.00 <br /> <br /> 3. PLANR~VIRW SECTION <br /> <br /> Marion Coun~ do~s not require a plan review. <br /> We will provide plan review ~c~ if you complet~ <br /> Section 5B a~ submit mo (2) ~B of plato and <br />~ s~ificafions wi~ ~is application. <br />MC 1541 <br /> <br />5. F]~S Al. Enler lolal of feea from Se, c. ii4 <br /> A2. Add $% surclmrge (.05 x Al) <br /> <br />B. ~l~r 25% of linc A 1 for Plan Review <br /> (Al + ,25), if ~quired <br />C. Inv~tigatlon Fee (ifrequircd) <br />D. Roimpeclion Fe~ (S25.00) <br /> <br /> TOTAL AMOUNT DUE <br />Roccipl No. <br /> <br />.] <br /> <br /> <br />