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FOR CIT~ USE O~LY <br />Received By:_ Date: <br />Zoning By: __ City: <br />Receipt #:. Amount: $ <br /> <br />IPLUM~ING PERMIT APPLICATION <br /> Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> 3150 Lancaster Dr. NE - Suite C <br />Salem, Oregon 97305 <br />8:00 am - 4:30 pm 24 hr. Inspection Lfme 373~427 FAX 588-7948 <br /> <br /> L Ft~E SCHEDULE (Complete m~d ~er totalln fi.A1 below) <br /> '~RESIDENTIAL ( ) COMMERCIAL ( ) GAS ( ) ELECTRIC <br /> <br />Pa~n~l ID: <br /> <br />P~I~ <br /> <br />I I~ NOT fi*FARTED WITHIN 180 DAIS OF,E~UANCE OR £F <br /> <br />Mailing Addr~s: <br />O~y: S~te: Zip: <br /> <br />I am the PROPERTY OI~3rER and I reside i~ or will reside in the completed <br />z~rttct~re and will be my own general eotWractor. I understand that I must <br />mgdster as a conxtmcE~n contractor if the stntemre is sold or offered for sale <br />before or ttl~On COmlMeOo~t Ill hire .nd, cono'actor~ 1 will hire only <br /> <br />Construction Contractors Boar~ I will immedkae~v notify A~wlon County of <br />Ovm~r s Signature <br /> <br />( )NEW ( )ADDITION ~ ALTERATION ( )RELOCATION <br /> <br />~ (New / Alt~raion) QTY.. QTY. <br /> <br />Wet Bar <br />Reconn~ct(perfixture) x $7.50 = <br /> <br />Water Lines <br />Residential:Fimtl00~,orfi'ac~onthe~of -- x $25.00 = $ <br />For ea addn1100 R, up to S00 feet -- x $16.00 = $ <br />Cormnemial:Firatl00~.,orfractionthcreof __ x $30.00 = $ <br /> Foreaaddn[ 100feet x $20.00 55 <br /> <br />~mliarv Sewer L~ <br />RcsidentiahFir~100fc, or fraction th~r~of -- x $35.00 = $ <br /> For ea adda1100 i~ up to 500 feet -- x $16.00 = $ <br />Coramercial:FirstlOOfl.,orfracfionthcreof -- x $~5.00 =$ <br /> Foreaaddnl lOOfeet ~ $20.00 =$ <br /> <br />Resideminl:Fir~tl0Ofc, or fraction th~acof -- x $35.00 <br />Foreaaddn1100tit, upt~500feet -- x $16.00 <br />Commorcial:Fitst lO0t~,orfraclionll~of __ x $35.00 <br />For ea addn1100 f~at, x $20.00 <br /> <br /> x $10.00 <br /> <br />Minor Instalin~ion Labels <br />Pack of 10 labels ~ $10.00 e~ch, <br /> sold only to Plumbing ~on~) <br /> <br />Dwelling permit L~bels <br />(For New Single Fem/ly Dwellings Only) <br /> <br /># of Lab~l~ @ N~: <br /> <br />One2Two Fanffi.v Dwe~ing Fee Square F~ x $ .09 = $ <br /> <br />Other (as required by the Building Official) <br /> <br />5. FEES <br />Al. B,4gE FEE As~ets~d on ~ APPLICATIOI~: <br /> (E~epfion: Water/Sewer Line Applications w/no fixture~ <br />A2. Entor total Fees f~om Section ~4 <br /> SUBTOTAI~ <br />A3. Add $ta~e Surcharge (.05% x A1 · A2) <br /> <br /> $ 2~.00 <br /> <br />B. Ent*r 30% of line A1 for Plsn R~view $ <br />C. hv~fion F~, ff~u~d $ ~ <br /> <br />E: ~dM~ P~ Rcviaw (~2.50~o~, m~m one h~hom) $ ~ <br />F. ~ f~ w~ch no f~ ~ s~cW~ ~ca~ (~2.50~, <br /> minim ~e ho~) $ ~ <br />O. ~ape~ion ~ide No~ B~M~a Horn (~2.50~, <br /> <br /> <br />