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FOR CITY USE ONLY R~ceived By: Date: Doning By: City: Receipt #: Amount: $ IPLUMBING PERMIT APPLICATION Please complete all Sections, 1 through 5 1 1. LOCATION OF INSTALLATION Parcel ID: Phone: q q q- 277 / 60 Oos S e Dfrec,o. : II PEP~glITS ARE NON-TRANSFEP~4BLE AND EXPIRE IF WORK] IS NOT ST/LRTED WITHIN 180 DdYS OF ISSUdNCE OR IF WORK IS SUSPENDED FOR 180 DAY~ 2A. CONTRACTOR INFORMATION Contractor: Mailing Address City: State: Zip: Phone: Fax: Plumbers License: Journeyman Plumbing License: Contractors Board Regislration Number: Conlractor's Signature: 2B. FOR ov~rNER INSTALLATION I am the PROPER~ O~ER and 1 r~ide in, or will r~ide in the completed st~cture a~ will ~ my own general contractor. I understa~ that I must before or u~n completion. If l hire subcontractor, I will him one su~ontractors re~stered with t~ Const~ction Contractors Board. lf l change my mind and do hire a general contractor who is registe~d with the Cons~ction Contractors Board, I will immediately not~ Marion County of t~ na~ of the con.actor: 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) seCq 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 373-4427 FAX 588-7948 4. FEE SCHEDULE (complete and enter total in 5-Al 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 # FLxtures Reconnect (per fixmre) Watar Lln~ Realdential: First 100 fl., or fraction thereof For ea addnl 100 ft, up to 500 fl -- Commercial: First 10~ fl., o~ fraction thereof For ea addnl I00 feet Residential: Fh'st 100 B., or fraction tbexeof For ea eddnl 100 fl, up to 500 ft Commercial: F~t 100 fl., or fraction th~of For ca addnl 100 fcct Storm Drains/Rain Drains Residential: First 100 ft., or fraction thereof For ca addn1100 IL up to 500 ft -- Commercial: First 100 B., or fraction thereof -- For ca addnl 100 feet Minor Installation Lal~ls Pack of 10 labels @ $10.00 each, sold only to Plumbing contractors) Dwelling Permit Labels (For New Stagle Family Dwellings Only) Onarl~o Family Dwelling Fe~: Square F~t: Other (as required by the Building Official) ( ) GAS ( ) ELECTRIC ( ) ALTERATION ( ) RELOCATION OTY. OTY. -- Interceptor -- Laundry Tub -- Shower Sink -- Trough Drain __ Tub/Shower Urinal Other -- x $15.00=$ 4 -- x $7,50 = $ '~ x $7.50 = $ -- 1 $25.00= $ 2 $16.00= $ $30.00= $__ $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 $20.00=$__ -- x $10.00=$ -- 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 Surcharge (~x A1 + Base Fcc) B. Enter 30% of line A 1 for Plan Review C. Investigation F*e (ff required) D. Ralnspection Fee ($50.00) E. Additional Plan Review ($62,50/hr, minimum one-half hour) F. Inspection for which no fee is s ($62.50/hr, minhnum one hour) G. Inspection Outside Normal Business Hours, ($62.50/hr, minimum two hours) TOTAL AMOUNT DUE