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FOR CITY VALIDATION <br />Received By: <br /> <br />IDate: <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 />IPLUMBING PERMIT APPLICATION <br /> P/ease complete all Sections, 1 through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> JOBADDRESS / q 31Z -~ l]e.o(,~ <br /> <br /> CITY ~ fl~ ~. O ~ <br /> PROPERTY O~ER <br /> <br /> I I I I-I I I <br /> c~oss s~urm~cno~s ~ O~ ~ <br /> PROJECT ~SCmpT~O~ ~ ~ pl~ <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 />-L 'lz.I z.I / <br />-I ,1 13 <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br /> Plumbing Contractor ~'t.//- L t~.n .,~ ,,.t <br /> Mailing <br /> <br /> Mb 131-1zlzl l <br /> <br /> [ <br /> <br />2B. FOR OW~R INSTALLATIONS <br />[~ope~ ~n~ ~lease prin0 <br /> M~ling Ad~e~s <br /> <br /> CiW, State, Zip <br /> <br /> Owner's Signatttre <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 />MC 15-45 7/97 <br /> <br />PERNIIT NO:¢~t'0~t~O / <br />Date: <br /> <br />Issued by: <br /> <br />4. FEE SCHEDULE (Comptete and enter total in 5-Al below) <br />RESIDENTIAL D COMMERCIAL ~ USE: <br /> NEW J~ ALTEP~.TION O ADDITION {~} RELOCATION <br /> <br />BASE FEE Assessed on all applications $20.00 <br /> (Exception: Water/Sewer Line Applications w/no fixtures) <br /> <br />FIXTURES OTY OTY <br />AREA DRAIN INTERCEPTOR <br />BACKFLOW pREV DEVICE LAUNDRY TUB <br />BATHTUB RECEPTOR <br />BIDET SHOWER <br />CATCH BASIN SINK <br />CLOTHES WASHER TROUGH DRAIN <br />DENTAL UNIT TUB/SHOWER <br />CUSPIDOR URINAL <br />DR1NKING FOUNTAIN ~ WATER CLOSET <br />FLOOR DRAIN j,~ WATER HEATER <br />OTHER WET BAR <br /> <br /> Total # Fixtures ~ x $10.00 = $ <br />Lawn vacuum breaker / sprinkler system -- x $4.50 = $__ <br /> <br /> Residential: First 100 ff., Or fraction the~of x$20.00 =$ <br /> For ea addn1100 ft Up to 500 feet -- x $15.00 = $ __ <br /> Commercial: First 100 ff. Or fraction thereof x $25.00 = $ <br /> For ea addn[ 100 feet x $15.00 = $ <br /> <br /> Residential: First l00 ff. Orfmetionthe~eof x$30.00 =$ <br /> Foreaaddnll0Oft. Upto500 feet __ x$15.00 =$__ <br /> Commercial: First 100 ff. Or fraction thereof x $30.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br />STORM DRAINS <br /> Residential: First 100 ft. Or fmetion thereof x $30,00 = $ <br /> ForeaaddnllO0ft. Up to 50O feat -- x$15.00 =$__ <br /> Commercial: For 100 ft. Or fraation thereof x $30.00 = $ <br /> For ea addnl 100 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 />DWELLING PERMIT LABELS # of Labels <br />(For New Single Family Dwellings Only) <br /> <br />5. FEES <br /> A [. Enter total of fees from Sec. gM <br /> <br /> A2. Add 5% sureharga (.05 x Al) <br /> <br />Subtotal <br /> <br />B. Emer 25% of IMe A ] for Plan Review <br /> (Al + .25), if required <br />C. Investigation Fee (if required) <br />D. Ret nspection Fee ($25.00) <br /> <br />N/C <br /> <br />Receipt No. <br /> <br />TOTAL AMOUNT DUE <br /> <br />' I <br />$ <br />$ <br />$ <br /> <br /> <br />