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FOR CITY VALIDATION <br />Received By: <br /> <br />Date: <br /> <br /> MARION COUNTY <br />BUILDING INSPECTION DMSION <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 />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />MECHANICAL PERMIT APPLICATION <br />P/ease complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> 1o 1-1 1 1-1 <br /> c oss <br /> <br /> PaO~CT D~SCmP~ON~D ~ ~ ~[ ~ <br /> <br /> PERM1TS ARE NON-TRANSFERABLE AND EXPIRE 1F WORK lS 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 />Mechanical Contractor <br />CONT~CTOR'S SIGNA.~ <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />Property Owner (please print) <br />Mailing Address <br /> <br />CtY, State, Z p <br /> <br />Owner's Signature <br /> <br /> Agent's Signalurc <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 />4. FEE SCHEDULE (Complete and enter total in Al below) <br />RESIDENTIAL ~" COMMERCIAL [~ USE:~Irt~nn.--~ <br /> NEW ~ ALTERATION ~ ADDITION {~ RELOCATION <br /> <br />GAS WATER HEATER ] x $7.50 = $ ~ <br /> Each outlet up to 4 outlets e~ x $%00 = $ ~'. ~ <br /> <br />OTHER (as required by the Building Official) <br /> <br />5. FEES Al. Enter total of fees from Sec. #4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br />B. Enter 25% of line A1 for Plan Review <br /> (Al + .25), if required <br />C. Investigation Fee (if required) <br />D. Reinspecfion Fee ($25.00) <br /> <br />Subtotal <br /> <br />TOTAL AMOUNT DUE $ <br /> <br />$~ <br /> <br />ReceiptNo. <br /> <br />MC 15-41 7/97 <br /> <br /> <br />