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FOR CITY VALIDATION <br />Received By: <br /> <br />Date: <br /> <br /> MARION COUNTY <br />BUILDING INSPECTION DMSION <br />31 $0 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: ~'t~t~'~ <br />Date: <br /> <br />Issued by: <br /> <br /> PLUMBING PERMIT APPLICATION <br />Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> JOBA~V~SS ~C~ ~ ~,~.R-?O0-~ <br /> <br />PROPERTY OWNER <br /> <br />OWNER'S <br />PHONE # <br /> <br />CRO SS STREET/DIRF. CTIONS <br /> <br />PROmCT DESCRIPTION <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 Comractor <br /> <br />Mailing <br />Address <br /> <br />PLUMBING BOARD NO. <br /> <br />CONTRACTORS BOARD <br />REGISTRATION NO. <br />JOURNEYMANS <br />PLUMBERS NO. <br /> <br />CONTRACTOR'S SIGNATURE <br /> <br />2B. FOR o~ArN'ER INSTALLATIONS <br /> <br />4. FEE SCHEDULE (Complete ~1 ~ter t~.al in 5-A1 below) <br />RESIDENTIAL ~ COMMERCIAL [~ USE: <br /> <br /> NEW ~ ALTERATION 0 ADDmON [~ RELOCATION <br /> <br />BASE FEE Assessed on all applications $20.00 <br /> (Exception: Wa~er/Sewer Line Applicafioes w/no fixtures) <br /> <br />FIXTURES OTY OTY <br />ARF~ DRAIN INTERCEPTOR <br />BACKFLOW pREV DEVICE LAUNDRY TUB <br />BATHTUB RECEFFOR <br />BIDET SHOWER <br />CATCH BASIN SINK ~ <br />CLOTHES WASHER TROUGH DRAIN -- <br />DENTAL UNIT TUB/SHOWER <br />CUSPIDOR URINAL <br />DRINKING FOUNTAIN WATER CLOSET ~ <br />FLOOR DRAIN WATER I~o~TER -- <br />OTHER WET BAR <br /> <br /> Total # Fixtures x $10.00 = $ <br /> <br />Lawn vacuum bn:~er / sprinkler system __ x $4.50 = <br /> <br /> Residential: Fi~t 100 IL, Or fraction thc~of -- x $20.00 = $ __ <br /> For ca addn1100 it Up to 500 f~:t <br /> Commercial: First 100iLOr frac~ionlhemof __ x$25.00 --$__ <br /> For ea addn1100 fi:et -- x $15.00 = $__ <br /> <br /> Residential: First 100 IL Or fraction <br /> For ea addal 10O IL Up to $00 feet -- x $15.00 <br /> Commemial: First 100it. or fractioathereof -- x$30.00 <br /> For ea addnl 100 feet -- x $15.00 = $ -- <br /> <br />STORM BRAINS <br /> Residential: First l00 iL Or fraction Uhemof -- x$30.00 <br /> Foreaaddnll00ft. UptoS00fee~ -- x$15.00 =$__ <br /> Commercial: For 100 <br /> Foreaaddnl 100 feet -- x$15.00 <br /> <br />MINOR INSTALLATION LABELS <br />(Pack of 10 labels @ $5.00 each, sold only to Plumbing contractors) <br />~ # of Labels N/C <br />(For New Single Family Dv,~llings Only) <br /> <br /> Agent's Signature <br /> <br />3. PLAN REVIEW SECTION <br /> <br /> Marion County does not require a plan review. <br />I <br />We will provide plan review service if you complete <br />I Seetiun 5B and submit two (2) sets of plans and <br />I specifications with this application. <br /> <br />MC 15-45 7/97 <br /> <br />5. FEES <br />Al. Enter I~ial of fees from ~c. #4 $ <br />A2. Add 5% s~rkarge (.05 x Al) $ <br /> Subtotal $ <br /> <br />B. Enter 25% of line Al for plan Review <br /> (Al + .25), if r~quired <br />C. Investigation Fee (if mquired) <br />D. Reinspection Fee ($25.00) <br /> <br />TOTAL AMOUNT DUE <br /> <br /> <br />