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FOR crl'Y USE ONLY <br />Received By: Date: <br />Zoning By: City:. <br />Receipt #: Amount: $ <br /> <br />LOCATION OF INSTALLATION <br /> <br />SitoAddress: 117 <br /> <br />Parcel Owner: <br /> <br />PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK <br />IS NOT STARTED WITHIN 180 DAIS OF ISSUANCE OR IF <br />WORK IS SUSPENDED FOR 180 DA IS. <br /> <br />2A. CONTRACTOR INFORMATION <br /> <br />Contractor: .~ <br />Mailing Address .~ ~/~V~/~- <br />City: S~te: Zip: <br /> <br /> Plumbers License; <br /> <br /> Joumeyrnan Plumbing License: <br /> <br /> Contractors Board <br /> Registration Number: <br /> <br /> Contractor's Signature: <br /> <br />2B. FOR OWNER INSTALLATION <br />Property Owner: (please print) <br /> <br />. i,ingA d s: //7 <br />c.y:Ma.,,.asv.,'zdc s te: C,v zip: '732.r <br />I am the PROPERTY OWNER and I reside in, or will reside in the completed <br />strueture and will be my own general contractor, l understand that l must <br />register as a construction contractor if the structure is sold or offered for sale <br />before or upon completion. Ill hire subcontractors, I will hire only <br />subcontractors registered with the Construction Contractors Board. lf l <br />change my mind and do hire a general contractor who is registered with the <br />Construction Contractors Board, 1 ~vill immediately notif~ Marion Coanty of <br />the name of the contractor.'~ <br /> <br /> Agent's Signature: <br /> <br />3. PLAN REVIEW SECTION <br /> <br /> Marion County does not require a plan review. We v.,ill provide plan review <br /> service if you complete Section 5B and submit two (2) sets of plans and <br /> specifications with this application. <br /> <br />MC 15-45 REV 3/99 <br /> <br /> MARION COUNTY BUILDING INSPECTION <br /> 3150 Lancaster Dr. NE - Suite C <br />Salem, Oregon 97305 <br />8:00am - 4:30pm 24 HR Inspection Line 373-4427 FAX 588-7948 <br /> <br /> lex <br /> q <br /> 4. sc. (comp,, C/7 ' / <br /> <br />( ) RESIDENTIAL ( ) COMMERCIAL <br />( )NEW ( ) ADDITION <br /> <br />Fixtu~ (New / Alteration) <br /> <br />Minor Installation Labels <br />Pack of 10 labels @ $10.00 each, <br /> sold only to Plumbing contractors) <br /> <br />Dwelling Permit Labels <br />(For New Single Family Dwellings Only) <br /> <br />Onet~wo Fanfily D~lling Fee: Square F~t: -- <br />Othea' (as required by the Building Official) <br /> <br />( )GAS ( )ELECTRIC <br /> <br />( ) ALTERATION ( ) RELOCATION <br /> <br /> OTY. OTY. <br /> Interceptor <br /> Laundry Tub -- <br /> Receptor <br /> -- Shower <br /> <br /> __ Trough Drain -- <br /> <br /> -- Tub/Shower <br /> Urinal <br /> <br /> -- Water Closet <br /> <br /> -- Water Heater <br /> Other <br /> <br /> __ x $15.00=$ 4 <br /> __ x $7.50 = $ -- <br /> / x $7.50 = $ I I <br /> <br /> x $25.00=$__2 <br />x $16.00=$__ <br />x $30.00=$__ <br />-- x $20.00=$ <br /> <br />x $35.00 = $ 2 <br />x $16.00=$ <br />x $35.00 = $ <br />__ x $20.00=$ <br /> <br />x $35.00 = $ 2 <br />x $16,00=$__ <br />x $35.00 = $___ <br />-- x $20.00=$ <br /> <br />-- x $10.00=$ <br /> <br />#of Labels __.@ $ NIC <br /> <br /> x $ .09 = $ -- <br /> $ <br /> <br />5. FEES <br /> <br />BASE FEE Assessed on ALL APPLICATIONS: <br />(Exception: Water/Sewer Line Applications w/no fixtures) <br /> <br /> Al. Enter total of fees from Section g4 <br /> <br /> A2. Add State Surcharge (.05% x Al + Base Fee) <br /> <br />$ 25.00 <br /> <br />B. Enter 30% of line Al for Plan Review <br />C. Investigation Fee (if required) <br />D. Reinspection Fee ($50.00) <br />E. Additional Plan Review ($62.50/hr, <br /> minimum one-half hour) <br />F. Inspection for which no fee is specifically indicated, <br /> ($62.50/hr, minimum one hour) <br />G. Inspection Outside Normal Business Hours, <br /> ($62.50thr, minmium two hours) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />SUBT~ <br /> $__ <br /> <br /> $ <br /> <br /> $__ <br /> <br /> $ <br /> $__ <br /> <br /> <br />