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MARION COUNTY <br /> <br />FOR CIT 31so Lancaster Dr. NE- Suite C <br />Received By: f~ /,~,~ Salem, Oregon 97305-1398 Date: <br /> <br /> Please complete all Sections, I through 5 I <br /> 4. FEE SCHEDULE (Complete and enter total in 5-Al b~low) <br /> <br /> M^RI0k ;0~I~-'/NT,AL 13 COMMERCI~ {3 VSE: <br /> <br />1. LOCATION OF INSTALLATION ... Ri III DiNG <br /> TAXACCO' NO' I I -Iq Iq I I 01010 <br /> <br /> cross ST~ETmI~CTIONS <br /> PRO'CT y~SCm~ION <br /> <br /> PE~TS A~ NON-~NSF~BLE ~ ~I~WO~ IS NOT <br /> ST~TED WlTH~ 180 DAYS OF ISSUANCE OR IF <br /> WO~ IS SUSP~DED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br /> Plumbing Contractor <br /> <br />Mailing <br />Address <br /> <br />EAX I I I I--I I I I--I I I I <br /> <br />CONTRACTORS BOARD <br />REGISTRATION NO. <br />JOIJRNEYMANS ~ JB <br />PLUMBERS NO. <br /> <br /> CONTRACTOR'S SIGNATURE <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />Property Owner (please prinO e~tl ~.lCl~ ~2:~a ae3 ~.~ <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 />MC 15-45 7/97 <br /> <br />;PECTION <br /> NEW ~ ALTERATION ~ ADDITION {~ RELOCATION <br /> <br />~ASE FEE Assessed on all applications ~"~ <br /> (Exception: Water/Sewer Line Applications w/no fixtures~ .... <br /> <br />OTY OTY <br />INTERCEPTOR <br />LAUNDRY TUB <br />RECEPTOR <br />SHOWER <br /> SINK <br /> TROUGH DRAIN <br /> TUB/SHOWER <br /> URINAL <br /> WATER CLOSET <br /> WATER HEATER <br /> WET BAR <br /> <br />FIXTURES <br />AREA DRAIN <br />BACKFLOW PREV DEVICE <br />BATHTUB <br />BIDET <br />CATCH BASIN <br />CLOTHES WASHER <br />DENTAL UNIT <br />CUSPIDOR <br />DPdNKING FOUNTAIN <br />FLOOR DRAIN <br />OTHER <br /> <br /> Total # Fixtures <br /> <br />Lawn vacuum breaker I sprinkler system ~t <br /> <br /> Residential: First l00 ff., Or fractlon thereof __ x$20.00 =$ <br /> Foreaaddnl 100 ft Up to 500 feet __ x$15.00 =$ <br /> Commercial: First 100 ft. Or fi'action thereof x $25.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br /> Realdeatia[: First 100 ff. Or fi'action thereof x $30.00 = $ <br /> Foreaaddnll00ff. Up to SOO feet __ x$15.00 =$ <br /> Commercial: First 100 ff. Or fi'action thereof x $30.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br />STORM DRAINS <br /> Residential: First 100ft. or fi'action thereof x$30.00 =$ <br /> For¢aaddn[100fi. Up to 500 feet __ x$15.00 =$__ <br /> Commercial: For 100 ft. Or fraction thereof x $30.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br />MINOR INSTALLATION LABELS x $50.00 = $ <br />(Pack of 10 labels ~ $5.00 each, sold only to Plumbing contractors) <br /> <br />~ # of Labels N/C <br />(For New Single Family Dwellings Only) <br /> <br />x $10.00 <br /> <br />x $4.50 <br /> <br />5. FEES <br /> Al. Enter total of fees fi~m Sec. <br /> A2. Add 5% surcharge (.05 x Al) <br /> Subtotal <br /> o <br /> B. Enter 25 ~/* of line A I for Plan Review <br /> (Al + .2S), i£req.k~d <br /> C. Investigation F~¢ (if required) <br /> D. Reinspectinn Fee ($25.00) <br /> TOTAL AMOUNT DUE <br /> Recelpt No. <br /> <br /> <br />