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MARION COUNTY <br />FOR CITY VALIDATION BUILDING INSPECTION DIVISION <br /> 3150 Lancaster Dr. NE - Suite C <br /> <br />Received By: Salem, Oregon 97305-1398 <br /> <br />Date: 24 HR Inspection Line 373-4427 <br /> Offi,: ph~o~ 588-FAX~5147' <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> mvl I I I=1 I I I-I I I I <br /> CROSS STREET/ <br /> <br /> STARTED 'WITHIN 180 DAYS OF ISSUANCE OR IF <br /> I <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />2B, FOR OWNER INSTALLATIONS <br /> <br /> Property Owner (p/ease print) <br /> <br /> Mailing Address <br /> <br />City, State, Zip <br /> <br />Owner's Signature <br />Agent's Signature <br /> <br />3. PLAN REVIEW SECTION <br /> <br /> Marion County does not requi~e 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 /> Date:. <br />a~,, 4:30pm Issued by:. <br /> <br /> ~AS 0 HC~CmC ~ <br />~?EE ASSESSED ON ALL APPLI_~}~i. CATIONS $10.00 <br /> FORCEDAIRUPTO I00.E~0BTU _' ~ x $6.00 =e <br /> FORCED AIR OVER 100.(~00 BTU x $7.00 = $ -- <br /> <br /> FLOORFUR~ACE x $6,00 =$- <br /> DUCTS (ALTERATION/EXTEnSION) -- x $7.50 = $ <br /> <br /> GAS FURNACE (over 100.(}~1 BTU) x $7.00 = $ __ <br /> GAS FIREPLACFdINSERT x $7.50 = $ -- <br /> GAS WATER HEATER x $7.50 = $ -- <br /> GAS LOG LIGHTER x $7.50 = $ -- <br /> GAS BARBEQUE x $7.50 = $ <br /> <br /> GAg PIPING <br /> Eachoufletupto4ol~dets ~ x $2.00 =$ <br /> Each additional outlet over 4 outlets x $~50 = $ <br /> <br /> SUSPENDED HEATER x $6.~0 = $ -- <br /> WALL HEATER x $6.00 = $ -- <br /> FLOOR MOUNTED x $6.00 = $ -- <br /> HEAT PUMP <br /> UNDER 3 TON x $6.50 = $ -- <br /> 3 TON AND MORE x SILO0 <br /> <br /> E~DHR~TUN ~ ~ S~.S0 =S I,~,06 <br /> 3 TON AND MORE x $11.00 <br /> EVAPORATIVE COOleR x $450 <br /> <br /> COML. EXHAUST SYS'fEM x $4.50 = $ -- <br /> COML. HOOD & EXHAUST x $4.50 = $ <br /> DOMESTIC RANGE HOOD x $4.50 = <br /> DOMESTIC EXHAUST FANS x $3.00 = $ <br /> DOMF~TIC DRYER VENTS x $3.00 = $ -- <br /> APPLIANCE <br /> no~ineludedinanapplian~permtt x $3.00 =$_ <br /> <br /> WOODSTOVE ! FIKEPLACE x $7.50 = $ __ <br /> FIRE DAMPER x $3.00 = $ -- <br /> COML/INDUSTRIAL INCINERATOR -- x $30.00 = $ -- <br /> <br /> OTHER (as reqnlted by the Building Official) <br /> DWELLING PERMIT LABELq # of Labels N[C <br /> <br />5. FEES <br />Al. Enter total of fees from Soc. gM $ ,~~ ~ <br />A2, Add 5% sureharge (.05 x Al) $ __ /t ~ <br /> <br />B. Enter 25% of line A1 for Plan Review <br /> (Al + .25), ff requlred <br />C. Inves6ga~n Fee (if requln~3 <br />D. Re~nspecfion Fee ($25.00) <br /> <br />TOTAL AMOUNT DUE <br /> <br />$ <br />$ <br /> <br />MC 15-41 7/97 <br /> <br /> <br />