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FOR CITY USE ONLY ~geceived By:. Date: Zoning By: City: Receipt#: Amount: PLU3'IBING PERMIT APPLICATION Please complete all Sections, 1 through 5 1. LOCATION OF INSTALLATION Cross Street/Directions: ~O0 k,~..~, ~ 'e.~ (~ '~ Project Description: PERMITS AR~ NON-T~SFEI~4BLE AND EX~IRE IF wool IS NOT STARTED WIThrlN lgO DAYS OF ISSUANCE OR IF WORff IS SUSPENDED FOR 180 DA YS. 2A. CONTRACTOR INFORMATION Ci*: ~ ~ State: 0 r Zip: S hi0 Jom~n Pluming License: 97 Contracw~ Boa~ Regis~afion Number: Contractor's Signature: ZT//L 2B. FOR OWNER INSTALLATION Property Owner: (pleaseprinO Mailing Address: City: State: Zip: I am the PROPERTY OI, IrNER and I reside in, or will reside in the completed structure and will be my own general contractor. I understand that I must ~gister as a construction contractor if the structure is soM or offered for sale before or upon completion, lf l hire subcontractors, 1 will hire only subcontractors registered with the Construction Contractors Board. lf l change my mind and do hire a general contractor who is registered with the Construction Contractors Board, I wilt immedtately notify Matqon County of the name of the contractor: Owner's Signature: Agent's Signature: 3. PLAN REVIEW SECTION Marion County does not require service if you complete Section specifications with this applicati MC 15-45 REV 2 NOTICE EFFECTIVE 7-1-99 STATE SURCHARGE CHANGE FROM 5% TO 7% 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 ~K~COMMERCIAL ( ) GAS ( ) ELECTRIC ( ) NEW ( ) ADDITION ( ) ALTERATION ( ) RELOCATION Fixtures (New / Alteration) OTY. OTY. Area Drain __ Interceptor Back/low Prevention Device -- Laundry Tub Water Lines Residential: First 100 fL, or fraction thereof -- x $25.00=$__2 For ea addnl 10~ fl, up to 500 fl x $16.00 = $ ~ Coramereiai: F~t 100 fl., or fraction thereof ] x $30.00 For ea addnl 100 feet Residential: First 100 fL, or fraction thereof -- Per ea addnl 100 f~ up to 500 ft Commercial: First 100 fL, o~ fraction thereof -- For ca addnl 100 feet Storm Drains/Rain Drains Residential: First 100 ft,, or fraction thereof -- For ea addnl 100 f~ up to 500 ft Contmer¢ial: First 100 fL, or fraction the~of For ea addnl 100 feet x $35.00=$__2 x $16.00 = $__ x $35.00 = $ -- x $20.00=$__ $35.00 = $ 2 $16.00 = $ ~ $35.00 = $ ~ $2o.oo = $ ~.~._''''~- Minor Installation Labels __ x $10.00 = $ -- Pack of 10 labels @ $10.00 each, sold only to Plumbing contractors) Dwelling Permit Labels #of Labels __@ $ (For New Single Family Dwellings Only) OneffwoFamgYDwlliagpee:Squa~eFeet: -- x $ ,09=$__ Other (as required by the Building Official) $ -- N/C BASE FEE Assessed on ALL APPLICATIONS: $ 25.00 (Exception: Water/Sewer Line Applications w/no fixtures) Al, Enter total of fees from S 'on ~4 / Z~; 50 '~ SUBTOTAL * ~ B. Enter 30% of Ihne Al for Plan Review $ C. Investigation Fee 0f required) D. Reinspeclion 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 hour) $ -- G. Inspection Outside Normal Business Hours, ($62.50/hr, minimum two hours) $ -- TOTAL AMOUNT DUE /.730.