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FOR CITY VALIDATION <br />Received By: <br /> <br />Date: <br /> <br /> MAR/ON COUNTY <br />BUILDING INSPECTION DIVISION <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305-1398 <br /> <br /> 24 HR Inspection Line 373-4427 <br />Office: phone 588-5147 8:00am - 4:30pm <br />FAX 588-7948 <br /> <br /> PLUMBING PERMIT APPLICATION I <br />Please complete all Sections, I through 5 <br /> I <br /> <br />1. LOCATION OF INSTALLATION <br />TA×^CCOUNTNO. I IIIA · <br /> <br /> CITY ' -- [ .... <br /> <br />PROPERTY OWNER <br /> <br />CROSS STREET/DIRECTIONS <br /> <br />i pRo.cT DESC ON h _ <br /> <br /> STATED WITH~ 180 DAYS OF ISSUANCE OR IF <br /> WO~ IS SUSPE~ED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br /> Plumbing Contractor <br /> <br />city <br />- I I I <br />~-, JB <br /> <br />Mailing <br />Address <br />PHONE I -- <br />FAX ~, <br /> <br />PLUMBING BOARD NO. <br /> <br />CONTRACTORS BOARD <br />REGISTRATION NO. <br />JOLIR2qEYIvlAIqS <br />PLUMBERS NO. <br /> <br />CONTRACTOR'S SIGNATURE <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> Property O,vner (pleaseprint~tS~ <br /> <br /> Phone I C[ol l-I , 17 le, l-I m't I t <br /> <br />3. PLAN ~W 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 />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />4. FEE SCHEDULE (Complete and enter totat in 5-Al ~low) <br />RESIDENTIAL ~ COMMERCIAL [~ USE: <br /> <br /> NEW [~ ALTERATION [~ ADDITION I-I RELOCATION <br /> <br />BASE FEE Assessed on all applications . ~ <br />~' (Exception: Water/Sewer Line Applications w/no fixtu,~ <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 />IN'I~RCEPTOR <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 __~'~ $10~ $__ <br />Lawn vacuum breaker / sprinkler system __ x $4.50 = $__ <br />WATER LINES <br /> Residential: First 100 fo, Or fraction thereof __ x $20.00 = $__ <br /> For ca addn1100 ~ Up to 500 feet __ x $15.00 <br /> Commercial: First 100 fi. Or fraction thereof x $25.00 = $ <br /> For ea addn1100 feet x $15.00 = $ <br /> <br />SANITARY SEWER LINES <br /> Residential: First 100 t~. Or fraction thereof x$30.00 =$ <br /> For ea addn1100 ft. Up ~o 500 feet __ x $15.00 <br /> Commercial: First 100 ~. Or fra~ion thereof x $30.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br />STORM DRAINS <br /> Residential: First 100 ff. Or fraction thereof x $30.00 = $ <br /> Foreaaddnll00ff. Up to S00 feet __ x$15.00 =$__ <br /> Commercial: For 100 ~. 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 onty to Plumbing contractors) <br /> <br />~i13-~[~/~ # of Labels N/C <br />(For New Single Family Dwellings Only) <br /> <br />5. FEES <br /> Al. Enter total of fees from S~c. ~4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br /> B. Enter 25 ~ of linc A 1 for Plan P-~view <br /> (Al + .25), if required <br />~nSfigation Fee (if required) <br /> speetion Fee ($25.00) <br /> <br />Receipt No. <br /> <br />Subtotal $ <br /> <br />TOTAL AMOUNT DUE <br /> <br />MC 15-45 7/97 <br /> <br /> <br />