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I I BUH,DING INSPECTION DIVISION PERMIT NO: <br />'[FOR CITY VALIDATION ] 3~5o Lancaster Dr. NE- Suite C <br />I .... I Salem, Oregon 97305-1398 <br />iKecelvea ~y: __ Date:__ <br />IDate: [ 24 ~..'.o~Line 373-4427 <br />/ -- [ Office: ~l~800am - 4:30pm Issued by: __ <br /> <br /> MECHANICAL PERMIT APPLICATIOIIIt~e~ $-~1~ 'l. FEESCnE.Ot~]LE~Complete~.d~nt¢.o~i.^~,ow, <br /> P/ease comp~ere all Sections, I through 5 I "' RESmENTIAL ~ COMMERCIAL [~ <br /> <br /> 1. LOCATION OF INSTALLATION BUILDING 1#SPEC' ~^s ~ ~Ecmc <br /> ~SE FEE ASSESSED ON ALL APPLICATIONS $10.00 <br /> <br />ST~D ~ 180 DAYS OF ISSU~CE OR WO~ 1S SUSPE~ED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />2B. FOR OWNER INSTALLATIONS <br />Property Own~f ~pt~ase print) ' <br />c~l,i~gta~iZ~ss <br /> <br /> Owner's Signature <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 />FURNACE <br />FORCI~ AIR UP TO 100,000 BTU <br />FORCED AIR OVER 100,0~0 BTU <br /> <br />FLOOR FURNACE <br />DUCTS (ALTERATION/EXTENSION) <br /> <br />GAS ]N,~TALLATIONS <br />GAS FUR3IACE (up to I00,000 ~TIJ) <br />GAS FURNACE (over 100,0(~ BTU) <br />GAS FIREPLACF~qNSERT <br /> <br />OTY <br /> <br /> x $6.00 = $ <br /> x $7.00 = $ <br /> x $6.~0 = $ <br /> x $7.50 = $ <br /> <br />x $6,(}0 <br />x $7.00 <br />x $7.50 <br />x $7.50 <br />x $7.50 <br />x $7.50 <br /> <br /> $2.00 <br />x $.50 <br /> <br />$6.00 <br />$6.00 <br />$6.00 <br /> <br />x $6.50 <br /> <br />=$ <br /> <br />=$ <br /> <br />x $4,50 =$ <br />x $4.50 =$__ <br />x $4.50 =$ <br />x $3.00 = $ __ <br />x $3.00 = $ __ <br /> <br />ADDITIONAL <br />WOODSTOVE Pi'~EI~E <br /> <br />5. FEES <br />A 1. Enter total of f~es from See. g4 <br />A2. Add 5% surcharge (.05 x Al) <br /> Subtotal <br /> B. Enter 25% of line A1 for Plan R~view <br /> (Al + .25), if required <br /> C. Investigation Fee (if required) <br /> D. Re~spec0on Fee ($25.00) <br /> TOTAL AMOUNT DUE <br /> <br />Receipt No. <br /> <br />MC 15-41 7/97 <br /> <br /> <br />