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Received By: <br />Date: <br /> <br />FOR CITY VALIDATION <br /> <br /> MARION 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 />Date: <br /> <br />Issued by: <br /> <br /> PLUMBING PERMIT APPLICATION <br />Please complete all Sections, 1 through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />PROPERTY OWNER <br />Pm R;8 I I I I--I I I I--I I I I <br />CROSS STREET/DIREC~ONS <br /> <br />PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br />STARTED WITHIN 1S0 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br />Plumbing Contractor <br /> <br />Mailing <br />Address City <br /> -I - <br />FAX ~- ~ <br /> <br />PLUMBING BOARD NO. I ~ I PB <br />CONTRACTORS BOARD <br />REGISTRATION NO. <br />JOURNEYMANS <br />PLUMBERS NO. ~ JB <br /> <br />CONTRACTOR'S SIGNATURE <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />Property Owner (please prinO~t~O~ <br />Mailing Address <br /> <br />Ciiy, State, Zip <br /> <br /> Owner'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 />FIXTURES <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 /> 4. FEE SCHEDULE (Complete and enter total in 5-Al below) <br /> RESIDENTIAL ~ COMMERCIAL ~ USE: <br /> <br /> NEW ~ ALTERATION ~ ADOITION {'1 REL~A~,~ <br />~A~SE FEE Assessed on all applications [ ' $20.00 <br />/~ ~_ (Exception: Water/Sewer Line Applications w/no fix~amsl ~ <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 1~ <br /> WATER HEATER b~?~.~ __ <br /> WET BAR "~ <br /> <br /> A <br /> Total # Fixtures ,e~ <br /> <br />Lawn vacuum breaker / sprinkler system <br /> <br />WATER LINES <br /> Residential: First 100tL, Or fraction thereof x$20.00 =$ <br /> ForeaaddalI00ftUptoS00feet __ x$15.00 =$ <br /> Commemial: First 100 iL Or fraction thereof x $25.00 = $ <br /> For ea addn1100 feet x $15.00 = $ <br /> <br /> Residential: First 100R. Or fraction thereof x$30.00 =$ <br /> Foreaaddnll00fl. Up to SOO feet __ x$15.00 =$ <br /> Commercial: First 100 IL Or fraction thereof x $30.00 = $ <br /> For ea addnt I00 feet x $I5.00 = $ <br /> <br />STORM DRAINS <br /> Residential: Firstl00fi. Or fi'action thereof x$30.00 =$ <br /> Foreaaddnl 100f~.UptoS00fect __ x$15.00 =$ <br /> Commercial: For 100 fl. Or fraction thereof x $30.00 = $ <br /> For ea addn1100 feet x $15.00 = $ <br /> <br />MINOR INSTALLATION LABELS x $50.00 = $ <br />(Pack of l0 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 />x $4.50 = $ <br /> <br />5. FEES <br /> Al. Enter total of fees from Sec. #4 <br /> A2. Add 5% surcharge (.05 x At) <br /> <br /> B. Enter 25% of line Al for Plan Review <br /> (Al + .25), if required <br />:i on Fee (if required) <br /> <br /> on Fee ($25.00) <br /> <br />Receipt No. <br /> <br />Sub~ctal $ <br /> <br />TOTAL AMOUNT DUE <br /> <br />MC 15-45 7/97 <br /> <br /> <br />