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..iON COUNTY <br /> I B~LD~G INSPE~ION DI~SION PE~IT NO: <br />IFOR CITY VALIDATION / 3150 L~ter ~. ~- Suite C <br />IReceived By: ~~1/~ Salem, O~gon 97305-1398 Date:~ <br /> ~ O~ce: .hone~~- 4:300m Issued by: <br /> <br /> P/ease complete afl Section~, ~ though 5 J ~ [ ~sc~[~uE~ (co~ct~ ~ :.~om~ in ~-~ ~o~) <br /> <br /> L~~--~-- ~0 ~ ~ COMMERCIAL ~ USE: <br /> ~W~ ~ON <br /> ' B~E FEE A~essed on <br /> (Exception: Watar/Sewer Line Appllcad~s w/no <br /> <br /> CROSS STREET/DIRECTIONS <br /> PRO~ECTDESCRIPT1oN 5 <br /> rratcLe~' ~ s3re <br /> PROJECrl)eSCKII'£1Ut~ .~ r~r~J~L~r' ~ Sq~-- <br /> <br /> PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <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 />Ad~'ess Ci <br /> <br />PHONE ~ ~- <br /> <br />FA~ <br />PLUMBING BOARD NO~ PB <br /> <br />REGISTRATION NO. <br /> <br />CONTRACTOR'S SIGNATURE <br /> <br />,B. FOR OWNER INSTALLATIONS <br /> <br />Agent's Signature <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 />AREA DRAIN <br />BACKFLOW PREV DEVICE <br />BATHTUB <br />BIDET <br />CATCH BASIN <br />CLOTHES WASHER <br /> <br />OTY OTY <br />INTERCEPTOR <br />LAUNDRY TUB <br />RECEPTOR <br />SHOWER <br /> SINK <br /> TROUGH DRAIN <br /> TUB/SHOWER <br /> UPdNAL <br /> WATER CLOSET <br /> WATER HEATER <br /> WET BAR <br /> <br /> Total # Fixtures x $10.00 <br />Lawn vacuum breaker / sprinkler system ] x $4.50 <br /> <br /> Residential: First 100 ft. Or fraction thereof __ x $20.00 = $ <br /> Foreaaddnl 100 ff Up to 500 feet __ x$15.00 =$ <br /> Commercial: First 100 ft. Or fraction thereof x $25.00 = $ <br /> For ca addnl I00 feet x $15.00 = $ <br /> <br /> Residential: First 100ft. Or fmction thereof x$30.00 =$ <br /> Foreaaddnll00ff. UptoS00 feet __ x$15.00 =$ <br /> Commercial: First 100 ft. Or fraction thereof x $30.00 = $ <br /> For eaaddnl 100 feet x$15.00 =$ <br /> <br />STORM DRAINS <br /> Residential: First 100 ft. Or fraction thereof x $30.00 = $ <br /> Foreaaddnll00ft. UptoS00 feet __ x$15.00 =$ <br /> Commercial: For 100 ff. Or fraction thereof x $30.00 = $ <br /> For ea addM 100 feet x $15.00 = $ <br /> <br />MINOR INSTALLATION LABELS x $50.00 = $ <br />(Pack of 10 labels ~ $5.00 each, soId only to Plumbing contractors) <br /> <br /> # of Labels N/C <br /> (For New Single Family Dwellings Only) <br /> <br />=$ <br /> <br />5. FEES <br />Al. Enter total of fees from Sec. #4 <br />A2. Add 5% surcharge (.05 x Al) <br /> Subtotal <br /> B. Enter 25°/6 of line A I for Plan Review <br /> (Al + .25), if required <br /> C. Investigation Fee (if required) <br /> D. Reinspection Fee ($25.00) <br /> TOTAL AMOUNT DUE <br /> Receipt No. <br /> <br />$ <br /> <br />MC 15-45 7/97 <br /> <br /> <br />