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FOR CITY USE ONLY Received By: Date: Zoning By: City: Receipt #: _Amount: $ PLUMBING PERMIT APPLICATION Please complete all Sections, 1 through 5 1. LOCATION OF INSTALLATION Parcel ID: Site Address: '~.t b~'~ ~n~C~ City: ~ld'120'fL~ ! ~c~r~ Zip: Parcel Owner:. ~ (~i ~ Pho. : z30 3- PERMITS ARE NON. TRANSFERABLE AND EXPIRE IF WORK IS NOT STARTED WITHIN 180 DAYS OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAYS. 2A. CONTRACTOR INFORMATION Contractor: .~r~..(. ~f.~ Mailing Address.'~O '~ 0 ~ I ~L~"O Ci~y.'~or~ s~ State:Ol,,~. ~x: ~O3-~1-033C Plumbers License: Contcactors Board C30'~len ~O O Registration Number: 2B. FOR OWNER INSTALLATION Pnaperty Owner: (p/ease print) Mailing Address: City: State: Zip: I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. I understand that I must register c~ a construction contractor if the structure is sold or offered for sale before or upon completion. If l lu're subcontractors, I will hire only subcontractors registered with the Construction Contractors Board, If l change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately watt'fy Ma~on County of the name of the contractor. MARION COUNTY BUILDING INSPECTION 3150 Lancaster Dr, NE - Suite C Salem, Oregon 97305 8:00am - 4:30pm 24 HR Inspection Line 373-4427 FAX 588-7948 4. FEE SCHEDULE (complete and enter total in 5.Al below) ( )RESIDENTIAL ( )COMMERCIAL ( )GAS ( )~LECTRIC ( )NEW ( )ADDITION ( )ALTERATION ( )RELOCATION Drinking Foumain ~~E~ Water Closet WetFinor Drain Bar ~ Other Water Heater Reconnect (per fLxtme) -- x $7.50 = $ -- Lawn Vacuum Breaker -- x $7.50 = $ -- Other Vacuum Breaker Devicez -- x $10,00=$__ Reaidenfial:~i~at 100 ~, or fracfion~e~f -- x $25.00=$__ x $16.00=$__ x $30.00=$__ -- x $20,00=$__ x $35.00=$__ x $16,00=$__ x $35.00=$__ -- x $20.00=$__ x $35.00=$__ x $16.00=$__ x $35,00=$__ -- x $20,00=$__ MinorlnslallatlonLabels -- x $10.00=$__ Pack of 10 labels @ $10.00 each, sold only to Plumbing conm~ters) Dwelling Permit Label~ gof Labels __@ $ (For New Single Family Dwellings Only) Om/YwoFamllyDweJllngF~e:SquareFeec -- x $ .09=$__ Other (as required by the Building Official) $ -- BASE FEE Assessed on ALL APPLICATIONS: $ (Exception: Water/Sewer Line Applications wino fixtures) Owner's Signature: Agent's Signature: 3. PLAN REVIEW SECTION 0(~'3 minimum one-half hour) $ __ ~ {~)~. Inspection for which no fee is specifically indicated, Marion County does not require a plan rcvicw. We will provide plan ~ ~]~ ($62.50/hr, minimum one hour) $ __ review service if you complete Section 5B and submit two (2) sets of ~., x.~ G. Inspection Outside Normal Business Hours. plans and specifications with this application. '~ · ($62.50/hr, minimum two hours) $ TOTAL AMOUNT DUE $ MC 15-45 R~v 9/98 N/C