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· MAR/ON COUNTY <br />· - BUILDING INSPECTION DIVISION <br /> FOR CITY VALIDATION 3150 Lancaster Dr NE-Suite C <br /> I Salem, Oregon 97305-1398 <br /> iReceived By: __ __ Date: . - ~ <br /> <br /> I ~~-"~ OIDce: phone 588-sin7 8:~am - 4:~pm ~ Q~qq~u~ by:. <br /> ~/ ~ -~/~/~/~, <br /> I PLUMB NG PE~MITAPPL GAT ON <br /> I P/ease comp~ere all Sections 1 through 5 4. ~E SCHEDUL~ (Compl. <br /> ~SIDENT~L ~ COM~RCI~ <br /> 1. LOCATION OF INSTALLATION <br /> <br />TAXACOO TNO' I 1'7 I OI /1 1--1010 I0 <br /> <br />PROPERTY OWNER <br /> <br />CROSS STREET/DIRECTIONS <br /> <br />PROJECT DESCRIPTION <br /> <br />PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT I <br /> I <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br /> Plumbing Contractor <br /> <br />Mailing <br />Add~ess City <br />:"x :1 - <br /> <br />CONTI~_CTOR'S SIGNATURE <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> Property Owner (please print) <br /> <br /> Mailing Address <br /> <br /> Ci~, State, Zip <br /> <br /> Owner's Signature <br /> <br /> Agent's Signature <br /> <br />3. PLAN REVIEW SECTION <br />IMarion 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 /> NEW ~ ALTERATION [] ADDITION ~ KELOCATION ~ <br /> <br />BASE FEE Assessed on all applications $20.00 <br /> (Exception: Water/Sewer Line Applications w/no fixtures) <br /> <br />AREA DRAIN <br />BACKFLOW PREV DEVICE <br />BATHTUB <br />BIDET <br />CATCH BASIN <br />CLOTHES WASHER <br />DENTAL UNIT <br />CUSPIDOR <br />DRINKING FOUNTAIN <br />FLOOR DRAIN <br />OTHER <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 /> Total # Fixtures x $10.00 = $ <br />Lawnvacuumbreaker/spfinklersystem __ x $4.50 =$__ <br /> <br /> Residential: First 100 ft., Or fracfion thereof x$20.00 =$ <br /> Foreaaddall00~Uptu500 feet __ x$15.00 =$__ <br /> Commercial: First 100 fl. Or fraction thereof x $25.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br /> Residential: First 100ft. Or fraetion thereof x$30.00 =$ <br /> Foreaaddnll00fl. Up to 500 feet -- x$15.00 =$__ <br /> Commercial: First 100 ft. Or fraction thereof x $30.00 = $ <br /> For eaaddn1100 feet x$15.00 = $ <br /> <br />STORM DRAINS <br /> Residential: First 100 ft. Or fraction thereof x $30.00 = $ <br /> Foreaaddnll00 ft. Up to 500 feet __ x$15.00 =$__ <br /> Corcanercial: For 100 ft. Or fraction thereof x $30.00 = $ <br /> For eaaddnl i00 feet x $15.00 = $ <br /> <br /> =$ <br /> <br />MINOR INSTALLATION LABELS x $50.00 <br />(Pack of 10 labels ~ $5.00 each, sold only to Plumbing contractors) <br /> <br />DWELLING PERMIT LABELS # of Labels N/C <br />(For New Single Family Dwellings Only) <br /> <br />5. FEES <br />Al. Enter total off~s from See. #4 $ <br />A2. Add 5% surcharge (.05 x Al) $ <br /> <br /> (~ln~?i) $ <br /> c. Invest~ati~Fee (it' required) $ <br /> D. Reinst~ion Fee ($25.00) $ <br /> TOTAL AMOUNT DUE <br /> <br /> <br />