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FOR CITY USE ONLY Receiv%d By:. Date: I .,.Zoning By: City: Receipt#: Amount: $ PLUMBING PERMIT APPLICATION Please complete all Sections, 1 through 5 I. LOCATION OF INSTALLATION Parcel ID: Pho,e: TF-- lqq7 Cross StreettDirections: Project Description: PER]flITS ARE NON-TP~NSFEIL4BLE AND EXPIRE IF WORK] IS NOT STARTED WITHIN 180 DAYS OF ISSUANCE OR IF WORE I$ SUSPENDED FOR lgO DAYS. CON , OR ,NFO ,ATION ' t O I MailingAddmss ~30 '"ffOh~O~ Icity: W,, t oorn zip: q707 ' Phone:( 'OJ) qg×-670 a- Fax: ,.mb Licen,,: TO .loumeyman Plumbing License: Registration Number: Contractor's Signature: Mailing Address: City: State: Zip: I am the PROPERTY OWNER and 1 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 soM or offered for sale before or upon completion, lfl hire subcontractors. I will hire only subcontractors registered with the Construction Contractors Board. lfl 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 provide 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 Dn 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 S-A1 below) ( ) RESIDENTIAL (~ } COMMERCIAL ( ) GAS ( ) NEW ( I ADDITION Flxtures (New / Alteration) Area Drain Bacldlow Prevention Device Bathtub Bidet Catch Basin Clothes Washer Dental Unit Cuspidor Drinking Fountain Floor Drain Wet Bar Total # Fixtures Reconnect (per fixture) Lawn Vacuum Breaker Other Vacuum Breaker Devices Residential: First 100 B., or fi.action thereof -- For ea adddi 1130 ft. up to 500 fl Commercial: First 100 fl., or fraction thereof ~ For ca addal 100 feet Sanitary Sewer Lin~ Residential: First 100 fl., or fracfion thereof -- For ca adddi 100 ft, up to 500 fl Commercial: Fha# 100 fl., or fraction thereof For ea addnl 100 feet Storm Drains/Rain Draina Residential: First 1 O0 fl., or fraction thareof __ For ca adddi 100 fl, up to 500 fl Commercial: First 100 ii., or fraction thereof -- For ea addnl 100 feet Minor Installation Labels Pack of 10 lahals @ $10.00 each, sold only to Pltmabing conlractors) Dwelling Permit Labels (For New Single Family Dwe0ings Only) Onarfwo Family Dwdling Fe~: Square Feet: -- Other (as required by the Building Official) ( ) ELECTRIC ( ) ALTERATION ( ) RELOCATION OTY. OTY. --. Interceptor Laundry Tub __ -- Receptor -- Shower -- Sink -- Tmugh Drain -- -- TuhiShower Urinal Water Closet Water Heater Other -- x $15.00=$__4 -- x $7.50 = $ -- -- x $7.50=$__1 __ x $10.00=$ $25.00 = $___ 2 $16.130=$__ $30.00 = $ -- $20.00 = $ __ x $35.00= $__2 x $16.00=$ x $35.00 = $ x $35.00= $__2 x $16.00=$__ x $35.00=$__ -- x $20.00=$__ -- x $10.00= $__ ~of Labels __.@ $ N/C x $ .09 = $ __ $__ 5. FEES BASE FEE Assessed on ALL APPLICATIONS: (Exception: Water/Sewer Line Applications w/no fixtures) Al. Enter total of fees from Section g4 A2. Add State Su~harge (.05% x Al + Base ,nee) SUBTOTAL B. Enter 30% of line A1 for Plan Review C. Investigation Fee (if requlred) D. Reinspecrion Fee ($50.00) E. Additional Plan Review ($62.50/hr. minimum one-half hour) F, Inspection for which no fee is specifically indicated, ($62.50/hr, minimum one ham') G. lnspe~tlon Outside Normal Business Hours, ($62.50/hr, minimum two hours) TOTAL AMOUNT DUE $ 25.00 $ $__ $__ $__ $__ $__