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FOR CITY USE ONLY Received By: Date: Zoning By: City: Receipt #: Amount: $ IPLUMlilNG PERMIT APPLICATION Please complete all Sections, I through 5 1. LOCATION OF INSTALLATION Parcel ID: ity: _ zip: Parcel Ow'aer: Phone: Cross Street/Directions: Project Description: I PERMIT~ ARE NON-TRANSFERABLE AND EXPIRE IF WOREI IS NOT STARTED WITHIN 180 DAYS OF ISSUANCE OR IF WORE IS SUSPENDED FOR 180 DAY~ 2A. CONTRACTOR INFORMATION MaitingAdaressl(aqZ~' 5.i.~. ~oq~ f~ I~1 zip: qTIqO Journeyman Plumbing License: 2B. FOR OWNER INSTALLATION Property Owner: (please prinO Mailing Address: City: State: Zip: I am the PROPERTY OFfNER and I reside in. or will reside in the completed structure and will be my own general contractor. 1 understand that 1 must register as a construction contractor if the structure is sold or offered for sale before or upon completion. If l hire subcontractors, I wilt hire only subcontractors registered with the Construction Contractors Board. lf I change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I will immediately notify Marion County of the name of the contractor: Owner's Signature: Agent's Signature: 3. PLAN REVIEW SECTION Marion County does not require a plan review. We will provMe plan review service if you complete Section 5B and submit two (2) sets of plans and specifications with this application. MC 15-45 REV 3/99 MARION COUNTY BUILDING INSPECTION 3150 Lancaster Dr. NE - Suite C Salem, Oregon 97305 8:00am - 4:30pm 24 HR Inspection Line 3734427 FAX 588-7948 4, FEE SCHEDULE (complete and enter total in S-A1 below) ( )RESIDENTIAL ( )COMMERCIAL ( ) NEW ( ) ADDIIION Fixtures (New / Alteration) Area Drain Backflow Prevention Device Bathtub Bidet Catch Basin Clothes Washer Dental Unit Cuspidor DrialOng Fountain Floor Drain Wet Bar Total # Fixiu~es Reconnect (per fixture) Lawn Vacuum Breaker Other Vacuum Breaker Devices Residential: First 100 ft., or fraction thereof -- For ea addal 100 ~ ap to 500 ft Commercial: First 100 ft., or fractloa thereof -- For ea addnl 100 feet Residential: Fimt 100 ft., or f~action theteof __ x Fo~ ea addnl 100 f~ up to 500 ft x CommerCial: First 100B.,orffactionthe~eof ~ x Fo~eaaddnl 10Ofeet ~ x Storm Drains/Rain Drains Residential: First 100 ft,, o~ fraction thereof x For ea addn1100 ft, up to 500 ft x Coramercial: First 100 ft,, o~ fraction thereof -- x For ea addui 10O feet x Minor Installation Labels x Pack of 10 labels .@ $10.00 each, sold only to Plumbing Dwelling Permit Labels gof Labels (For New Single Family Dwellings OMy) One/lX~FamilyDwellingF~e:SquamFeet: -- x Other (as reqim~.d by the Building Official) ( )GAS ( )ELECTRIC ( ) ALTERATION ( ) RELOCATION OTY. OTY. lntew~ptor -- Laundry Tub -- -- Receptor Shower Sink -- Trough Drain -- -- Tub/Shower Urinal Water Closet water Heater Other __ x $15.00=$ 4 -- x $7.50 = $ -- -- x $7.50=$__1 -- x $10.00=$__ x $25.00 = $ 2 x $16.00=$__ x $30.110 = $__ -- x $20.00=$__ $35,00=$__2 $16,00 =$__ $35.00 = $ __ $20.00 = $ -- $35.00 = $ --2 $16.00 = $ __ $35.00 = $ -- $20.00 = $__ $10.00 = $ -- @ $ NIC $ .09 = $__ $__ BASE FEE Assessed on ALL APPLICATIONS: (Exception: Water/Sewer Line Applications wino fixtures) Al. Enter total of fees from Section g4 A2. Add Smt~ Sureharg~ (.05% x A1 + Bose Fee) SUBTOTAL B. Enter 30% of line A1 for Plan Review C. Investigation Fee (if required) D. Reinspection Fee ($50.00) E. Additional plan R~view ($62.50&r, minimum one-half hour) $ -- F. Inspection for which no fee is specifically indicated, ($62.50/in', miuimum one hour) $ -- G. Inspection Outside Normal Business Hours, ($62.50/1a', minimum two hour) $ -- TOTAL AMOUNT DUE $.__ $ 25.00