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FOR CITY USE ONLY Received By:. Date: Zoning By: City:_ Receipt #: Amount: $ PLUMBING PERMIT APPLICATION Please complete all Sections, 1 through 1. LOCATION OF INSTALLATION Phone: Cross S~effDirections: PERMITS ARE NON-TRANSFERABLE AND EXPIRE IFwoRKI IS NOT STARTED [YiTHIN 180 DA YS OF ISSUANCE OR IF I WORK IS SUSPENDED FOR 180 DAYS. I 2A. CONTRACTOR INFORMATION Mailing Address // 7 (n~d~'~ ~/~ '~. City~/4g'L/l '{4t~.~ State: t~' Zip: Fax: Plumbe~ License: Journeyman Plumbing License: Contractors Board Registration Number: Contractor's Signature: 2B. FOR OWNER INSTALLATION Proper~ Owner: (please prinO Mailing Address: City: State: Zip: 1 am the PROPERTY OWNER and 1 reside in, or will resMe 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 sold or offered for sale before or upon completion. IfI hire subcontractors. I wiB hire only subcontractors registered with the Construction Contractors Board. Ill change my mind and do hire a general contractor who is registered with the Construction Contractors Board, 1 will immediately notify Marion County of the name of the contractor.- 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 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 5-Al below) ( .d)'RESIDENTIAL ( ) COMMERCIAL ( ) GAS ( )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 fixtam) Lawn Vacuum Breaker .~ Other Vacuum Breaker Device~ Water Lines Residential: First 100 ft., or fraction thereof __ For ea addn1100 fL up to 500 ft __ Cormnercial: First 100 R., or fraction thereof For ea addnl 100 feet Residential: First 100 ft., or fraction thereof __ For ea addn1100 fL'up to 500 ft __ Commercial: First 100 B., o~ fraction thereof -- For ea addnl IE0 feet Storm Drains/Rain Dratun Residential: First 100 B., c~ fraction thereof -- For ea addnl 100 fL up to 500 ft Commercial: First 100 B., or fraction thereof -- For ea addn1100 feet ( ) ELECI?dC ( ) ALTERATION ( ) RELOCATION OTY. OTY. __ Interceptor -- Laundry Tub __ -- Receptor Shower __ Trough Drain -- Tub/Shower Urinal -- Water Closet Water Heater Other __ x $15.00=$__4 __ x $7.50=$ I x $7.50 = $ / l __ x $10.00=$__ x $25.00=$__2 x $16.00=$__ x $30.00 = $ __ x $20.00=$__ x $35.00=$__2 x $16.00=$__ x $35.00=$__ x $20.00=$__ x $35.00=$__2 x $16.00=$__ x $35.00=$__ -- x $20.00=$__ Minor Installation Labels __ x $10.00 = $ __ Pack of 10 labels ~ $10,00 each, sold only to Plumbing contractors) Dwelling Permit Labels #of Labels __@ S N/C (For New Single Family Dwellings Only) Onet'I~oFamilyDwdlingFee:Squar:Feet: -- x $ .09=$__ Oth~' (as required by the Building Official) $ __ 5. FEES BASE FEE Assessed on ALL APPLICAFIONS: (Exception: Watex/Sewer Line Applications w/no fixtures) Al. Enter total of fees from Section tM A2. Add State Surcharge (.05% x Al + Base Fee) B. Enter 30% of llne Al f~ Plan Pa:view C. Investigation Fee (if required) D. Reinspection 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, mMimum two hours) TOTAL AMOUNT DUE $ 25.00 $__