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POR~I'P~ USg ONLY Received By: Date: Zoning By: City:. Receipt #: Amount: PLUMBING PERMIT APPLICATION Please complete all Sections, I through 1. LOCATION OF INSTALLATION Parcel ID: Site Address: ~ City: i~.--~ ~,-~S'O,.~g~ ~ Zip: Phone: Cross Street/Directions: Project Description: ~ PERMITS ARE NON-TRANSFERABLE .&ND EXPIRE IF WORK IS NOT STARTED SI'TI'HIN 180 DAYS OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAY'S, 2A. CONTRACTOR INFORMATION I Phoney ~ ~ ~o ~a~f- Plumb~ Licen~: Journeyman Plumbing License: Contractors Board Registration Number: Con'a'acinr's Signature: 2B. POR OWNER INSTALLATION Property Owner: (please prinO Mailing Address: City: State: Zip: I am the PROPERTY OWNER and I reside in, or will reside in the completed structure and will be my own general contractor. I understand that 1 must register 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 Boant. 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 service if you complete Section specifications with this applicati I*IC 15-45 REV 2 NOTICE EFFECTIVE 7-1-99 STATE SURCHARGE CHANGE FROM 5% TO 7% 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 S-A1 below) ( ) RESIDENTIAL ( ) COMMERCIAL ( ) NEW ( ) ADDITION Fixtures (New / Alteration) Area Drain Backflow 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 Brealmr Devices Residential: First 100 ft., or fraction thereof -- For ea addn1100 ft, up to 500 B Commercial: First 100 ft., or fracdon thereof -- For ea addnl 100 feet Residential: First 100 ft., or fraction thereof -- For ea addnl 100 ft, up to 500 B Commercial: First 100 ft., or fraction thereof . For ea addnl 100 fe~t Stor Dr i i rain Residential: First 100 fi., or fraction thereof For ca addnl 100 ft, up to 500 fr Commercial: First 100 fi., or fraction thereof -- For ea addnl 100 feet Minor Installation Labels Pack of 10 labels @ $10.00 each, soM only to Plumbing contraclors) Dwelling Permit Labels (For New Single Family Dwellings Only) Onet'rwo Family Dwelling Fee: Square Fe~t: -- Other (os required by thc Building Official) ( } GAS ( ) ELECTRIC ( ) ALTERATION ( ) RELOCATION OTY. OTY. -- Interceptor -- Laundry Tub __ -- Receptor __ Shower Sink Trough Drain -- -- Tub/Shower -- Urinal -- Water Closet -- Water Heater -- x $15.00=$__4 -- x $7.50 = $__ __ x $7.50=$__1 x $25.00 = $ 2 x $16.00 = $ x $30,00 = $ -- x $20.00=$__ $35.00 = $ 2 $16.00=$__ $35.00 = $ __ $20.00 = $ __ x $35.00=$__2 x $16.00=$__ x $35.00=$__ __ x $20.00=$__ -- x $10.00=$ gof Labels @ $ N/C x $ .~9 = $ -- $ 5. FEES BASE FEE Assessed on ALL APPLICATIONS: $ (Exception: Water/Sewer Line Applications w/no fixtures) Al. Enter total of fees from Section ~4 $ -- A2. Add State Surcharge (.05% x A1 + Base Fee) $ -- SUBTOTAL B. Enter 30% of line Al for Plan Review C. Investigation Fee (if reqolred) ,. Rein ction.ee (*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 bear) $ G. Inslx:Ction Outside Normal Business Hours, ($62.50/hr, minimum two hours) $ TOTAL AMOUNT DUE $__