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[eceFOR CITY VALIDATION <br /> <br /> ived By: <br /> <br /> MA~ON CO~/~_ A <br />BUILDING INSPECTIOy~t~ I PERMIT NO: <br /> <br /> Sal,m, o=gon 9730s4~ <br /> <br />1. LOCATION OF INSTALLATION <br /> T ACCO NO'I I I I I I--I I I <br /> ~, fftb~wlle ~ q~733,~ <br /> <br /> OWNER'S ~ ~ <br /> ~OSS S~I~C~ONS <br /> <br />PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br />STARTED WITHIN 1~0 DAYS OF ISSUANCE OR IF <br /> WORK [S SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR 131STALLATION ONLY <br /> <br /> ISIo la I-Iw <br /> 151o 13 I-Iq <br /> PLUMBING BOARD NO. <br /> <br /> CONTRACTORS BOARD <br /> REGISTRATION NO. <br /> JOURNEYlvLA~S <br /> PL~EP.S NO. <br /> <br /> CONTRACTOR'S SfGNATORE <br /> <br />2B. FOR OWNER INSTALLATIONS <br />Prolm~ Owner (please print) <br /> t6~iling Address <br /> <br /> City, Sm~, Zip <br /> <br /> Owner's Signature <br /> <br /> Agent's Signature <br /> <br />3. PLAN REVIEW SECTION <br /> <br /> Marion County does not require a pla~ Yeview. <br /> We will provide plan review service if you complete <br /> Section 5B and submit two (2) sets of plans and <br />I specifications with this application. <br /> <br /> NEW ~ ALTERATION ~/'ADDITION I'"l RELOCATION <br /> <br />BASE FEE Assessed on all applications $20.00 <br /> (Exception: Water/Sewer Line Applications w/no f~ma'es) <br /> <br />ltlXTLrl~S OTY <br />AREA DRAIN ~R <br />BACKFLOW PREV DEVICE LAUNDRY TUB <br />BATHTUB RECEPTOR <br />BIDET SHOWER <br />CASH 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-~ATER ~ <br />OTHER WET BAR <br /> <br /> Total # Fixtu~s ~ x $10.00 <br /> <br />Lawn vacuum breaker / sprinkler system __ x $4.50 <br /> <br /> Residential: First l00 iL, Or fraction the~of -- x$20.00 --$__ <br /> For ea atklnl 100 ft Up to 500 feet __ x S15,00 <br /> Comn~rc'mh Fit'st 100 ff. Or traction tl~mof x $25.00 = $ <br /> For ea addnl 100 f~'t x $15.00 = $ <br /> <br /> Reaidenl~al: Firatl00ft. Orfnaclionlhe~eof x$30.00-$ <br /> For ea addnl 100 ft. Up to 500 fe~ __ x $15.00 <br /> Commercial: Fi~t 100 f~. Or fraction thereof x $30.00 = $ <br /> Foreaaddnl 100 feel x$15.00 =$ <br /> <br />h~TORM DRAINS <br /> Re~idnsfial: Fi~100R. Or fraction lhemof x$30.00 ~$ <br /> For ea addnl 100 fl. Up to 500 f~t x $15.00 <br /> Commercial: For~ i00 fl. Or fraction thereof x $30,00 ~ $ <br /> For ea addnl 100 feet .tx $15,00 - $__ <br /> <br />~[~,~ # of tal~l, <br />(For N~w Single Family Dwellings Only) <br /> <br />. ,Io. ~o <br />~$ <br /> <br />5. FEES <br /> <br />B. Enter 25*/* of lin~ Al for Plan Review <br /> (Al + .25), if required <br />C. Investigation Fee (if required) <br />D. Relnapecfion Fee ($25.00) <br /> <br />TOTAL AMOUNT DUE <br /> <br />,3V. oo <br />s~ <br />S <br /> <br />$ <br />s/.~'-7~c; o <br /> <br />MC 15-45 7/97 <br /> <br /> <br />