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FOR CITY USE ONLY Received By: Date: Zoning By:_ City; Receipt #:_ Amoum: $ q PLUMBING PERMIT APPLICATION ] Please complete all Sections, 1 through 5 L LOCATION OF INSTALLATION Parcel ID: Site Address: { [ ~ ~4 L~ -- City: ~ Zip: City: ~ Phone: PERMIT~ ARE NON-TRAlCSFERABLE AND EXPIRE IF WORK IS NOT STARTED WITHIN 180 DA Iqg OF ISSUANCE OR IF WORK IS SUSPENDED FOR l go DA YS. lA. CONTRACTOR INFORMATION Mailing Address / city: c o.e: 589- Plumbers License: ~.. Registmtinn Number: 2B. FOR OWNER INSTALLATION Property Owner: (please prinO Mailing Addreas: City: State: Zip: I am the PROPERTY OWNER and t reside in. or will reside i)t the completed structure and will be my own general contractor, l u.derstand that l must register as a construction contractor if the slructure is sold or offered for sale before or u~on completion. Ill hire subcontractors. I will hire only antbcontractorsregisteredwiththeConstructionContractorsBoart~ Ill change m), mind atut do hire a general contractor who is registered with the Co~t*truction Contractors Board, I will immediately notify ^~atqon CounO, of t~ naote of the contractor: Owner's Signature: Agent's Signature: 3. PLAN REVIEW SECTION Marion County does not require a plan review. We will provide plan review service if you complete Section 5B m~d submit two (2) sat~ of plans and specifieatinns wifl~ this application. 3150 Lancaster Dr. NE - Suite C ~.~ Salem, Oregon 97305 8:00 am - 4:30 pm 24 lur. Inspection Line 373-4427 FAX 588-7948 FEE SCBEDULE (Complete m~d enter total in 5-Al below) ~RESIDENT[AL ( )COMMERCIAL ( )GAS ( )ELECTPdC ~NEW ( )AI)DITION ( ) ALTERATION ( )RELOCATION Area Drain __ Interceptor Backllow Prevention Device _J_ Laundry Tub Bathtub __~__ Receptor Bidet Shower Catch Basin Sink Clothes Washer __ Trough Drain Dental Unit Tub/Shower Cuspidor Urinal Floor Drain Water Heater Wet Bar Other Total#Fixtures; [ x $15.00 -- $.~ Re~onn~ct(perfix~ure) x $ 7.50 Lawn Vacuum Breaker × $ 7.50 = $ Other Vacuum Breaker Devines ~] x $10.00 Residential: First 100 iL. or fraction thereof x $25.00 - $ ForeaaddnllOOfl. up to S00 feet __ x $16.00 = $ Commercial:Fi~t 100ft.,orfractinnthereof x $30.00 - $ Foreaaddnl 10Ofeat x $20.00 -$ Sanlta Sewer L~nes Residential: First 100 iL, or fraction thereof x $35.00 Foreaaddnl 100ft, uploS00t'eet __ x $16.00 Commercial:Fimt 100 iL, or fraction thereof x $35.00 For ea addn1100 feet x $20.00 Storm Drains. Residential: Fir~ 100 IL. or fracfionthereof x $35.00 For ea addn1100 fl. up to 500 feet x $16.00 CommerciahFi~t 100 ft., or fraction thereof x $35.00 Forea addn1100 feet x $20,00 MAnor Installation LabeLs Pack of 10 labels (~ $10.00 each, sold only to Plumbing contraclo~) x $10.00 =$ Dweging Permit LabeLs (For New Single Family Dwellings Only) # of Labels One/Two Fandly I~'elling Fee Square Feet: x $ .09 Other (as requh-ed by the Building Official) (~ N/C $ 5. FEES Al. BASE FEE Assessed on ALL APpLIC~4 TIONS: (Exception: Water/Sewer Line Applications w/no lix~.ures A2. Enter total Fee~ from Section ~4 SUBTOTAL: A3. Add State Surcbargn (.05% x Al i A2) B Enter30%oflineAI for PlanReview C inveslignlion Fee. if required D. Reinspection Fee ($50.00) E Additional Pl:m Review {$62.50tltour. tnininmm one hal£hour) F. Inspection for wtlich no lee is specifically indicated ($62.50/hr, mininmm one hour) G. [nspectinn OuLqide Nomml Business Hours ($62.50/hr. mininmm two hours) TOTAl, AMOUNT DUE