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FOR CITY VALIDATION <br />Receiv~ By: <br /> <br />Date: <br /> <br /> ',.ONCOUNTY <br />BUILDING INSPECTION DIVISION'-- ~ PE~ N~ <br /> 3150 L~c~ter Dr. ~ - Suite C <br /> Salem, Oregon 97305-1398 ~[P -' 3 .... Da~: <br /> ~ ~ l~on L~e 373~27~aalfl~ <br /> O~ce: pho~ 5~5147 8:~m - 4:~ss ..... ----~u~d b~' <br /> FAX 58~7948 BUILDING INSPt~ <br /> <br />IMECHANICAL PERMIT APPLICATION I <br />Please complete all Sections, 1 through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> °.oWoWoW ;S I-'1719' ;I-Iq1 <br />CROSS STREET/ <br /> <br /> PROJECT DESCRIPTION ~'.,l..'~ ~.~/ <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 /> Property Owner (please print) <br /> <br /> Mailing Address <br /> <br /> City, S~a~e, Zip <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 />4. FEE SCHEDULE (Complete and enter ~otal in A1 below) <br />RESIDENTIAL~ COMMERCIAL ~ USE: <br />NEW [~ ALTE~TIO~J~ ADDITION [~ P-~OCATION [~ R~PLACE <br /> GAS ~ ELECTRIC ~} <br />BASE FEE ASSESSED ON ALL APPLICATIONS ~ <br /> <br /> FURNACE OTY <br /> FORCEDAIRUPTO 100,000BTU x $6.00 =$ <br /> FORCED AIR OVER 100,000BTU x $7.(]0 =$ <br /> <br /> FLOOR FURNACE x $6.00 = $ __ <br /> DUCTS (ALTERATION/EXTENSION) x $7.50 =$ __ <br /> GAS INSTALLATIONS <br /> GAS FURNACE lup to 100,000 BTU) x $6.C0 = $ __ <br /> GAS FURNACE (o~,~ 100,O00 BTU) x $7;00 = $ .- <br /> GAS I~REPLACF~TNSERT x $7.50 = $ <br /> GAS WATER HEATER x $7.50 -- $ <br /> GAS LOG LIGHTER x $7.50 = $ <br /> GAS BARBEQUE x $7.5~ = $ <br /> <br /> GAS PIPING <br /> Each out[et up to 4 outlets f x $2.00 = $ ~ <br /> Each additional outlet over 4 troffers x $.50 = $ __ <br /> <br />woot, s~ov~ ~c~ / ~ $7.5o -- $ ~ <br /> <br />~ # of Labels ~N/C <br /> <br />5. FEES Al, Enter total of fees from Sec. <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br />B. Enter 25% of line A 1 for Plan Review <br /> (Al + .25), if mquked <br />C. Investigation Fee (ff lequited) <br />D. Relnspection Fee ($25.00) <br /> <br />Receipt No. <br /> <br />TOTAL AMOUNT DUE <br /> <br />MC 15-41 7/97 <br /> <br /> <br />