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IFo. omc, use <br />[Receiv~a by: . <br />Date: <br /> <br />IPLUMBING PERMIT APPLICATION I <br />Please complete all Sections, 1 through 5 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />220 High Stxeet NE <br />Salem, Oregon 97301 <br /> <br />Phone 588-5147 8;00 a.lm - 4:~0 <br /> Code-A-Phone: 588-7904 <br /> PAX: 585-7948 <br /> <br />SITE #: <br /> <br />Date; <br /> <br />Issued by: <br /> <br />Permit No, <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />,,°',,Add,,,,, <br /> <br /> . <br /> [ c~o,,s~ Lar/4'~,~cwT <br /> <br />Dhcctiona <br /> <br />PERMITS AI~E NON-TRANSFI3RABLE AND NON-RPA~IJNDABLE AND <br />· EXPIRE IF WORK IS NOT STARTED WITHIN 180 DAYS OF ISSUANCE <br /> <br />OR IF WORK IS SUSPENDED FOR 180 DAYS- <br /> <br /> 2A, CONTRACTOR INSTALLATION ONLY <br /> <br />Contracto¢ <br /> <br />Mailing Address <br /> <br />Property Owner <br /> <br />Contmetoes Licen~ No. <br /> <br />'[ Phone <br /> <br />Phone <br /> <br />Ilob No. <br /> <br />FOR OWNER INSTALLATIONS <br /> <br />Mailing Address Phone <br /> <br />City/St~t¢/'Eip <br /> <br />The inst~llation is being made on pmpez~y I own which is not intended for aalc, <br /> <br />3. PLAN REVIEW SECTION <br /> <br />We will provide plan review service if you complete Section <br />5B and submit two (2) sets of plans and specifications with <br />this application, <br /> <br />This optional plan review pwgram dc~s not suspend the <br />required submission of plans, and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 53. <br /> <br />4, FEE ScI:I~DULE (Complete al3d anter total in A1 below) <br /> [] co acI <br /> <br />NO, XFEE =SUM <br /> <br /> $20,00 <br /> <br />BASE FEE <br />A. RESIDENTIAL <br /> <br /> Single Family or m~ti-Family per <br /> dwelling unit (each fixture) <br /> New constmetion -- $ 9.00 <br /> Alterations --$ 9.00 <br /> Re-located structure __$ 4.50 <br /> <br /> Water Lines <br /> First 100 R. or fraction thereof --$20.00 <br /> For additional 1 O0 h. (up to <br /> maximmm of 500 feet) __ $15.00 <br /> <br /> Sewer Lines <br /> First 100 feet or fractian thereof __,$30,00 <br /> For additional 100 feet (up to <br /> maximum 500 feet) __,$15,00 <br /> <br />B. COMMERCIAL (each fixture) <br /> <br /> New con$~xuction $ 9.00__ <br /> Alterations --, $ 9,00 <br /> Re-located structure __, $ 9,00 <br /> <br /> Water Lines <br /> First 100 feet or fraction thereof <br /> For additional 100 feet <br /> <br /> Sewer Lines <br /> First 100 feet or fraction thereof __ <br /> For additional 100 feet __ $15.00 <br /> <br />C. LAWN SPP, YN-KLER SYSTEM <br />Each protective backflow device --$ 4.50 <br /> <br />D. OTHER (as tegdired by OSPSC and <br /> Building Officml) <br /> <br /> $20,00 <br />--$15.00 ............. <br /> <br />5. FEES <br />Al. Enter total of tees from Sec. # 4 <br />AZ, Add 5% surcharge (,05 x Al) $ <br /> <br /> Subtotal $ <br /> Enter 25% of line A1 for Plan R~view <br /> (.25 x Al) ifre~uirad $ <br /> Investigation Fee(if required) $ <br /> D. Reinspeetion Fee $ <br /> <br /> TOTAL AMOLrNT DUE $ <br /> <br />No. <br /> <br />~C ]~.4~ <br />Rev, ~/92 <br /> <br /> <br />