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FoR O~iCECEUS~US ONLY MARION COUNTY BUILDING INSPECTION <br /> <br /> Received b~y4 . ~'~/l~ ~ 220 High Street ~ <br /> Date: ~ /.~],L~ Sa/~km, Oregou97301 <br />I ' A ,, ~ ' [~ <br /> PLUMBING PERMIT APP,LICATION I "'~'s~A~O 4 1995 Date: __ <br /> P/ease comp~ere a/I Sections, 1 through 5 <br />I ~ MARION COUNT'/~ssued by: <br /> ]. LOCATION OF INSTALLATION BUILDIN <br /> <br /> ca~ D~."7~_E ,~' ] c~o~,~, Lf¢/C/*7.~ ~-. <br /> ~'t <br /> <br />PERMITS ARE NONiTRANSFEILa-ELE AND NON-R~FLrNDABLE AND <br />EXPIRE IF WORK tS NOT STAR. TED WITH IN IS0 DAYS OF ISSUANCE <br />OR IF WORK IS SUSPENDED FOR. IS0 DAYS. <br /> <br /> lA, CONTRACTOR INSTALLATION ONLY <br /> <br />Ma/llng Address <br /> <br />Board Res, No, <br /> <br />Job No, <br /> <br />2B, FOR OWNER INSTALLATIONS <br /> <br />Permit No, <br /> <br /> [] RESIDENTIAL ~ COMMERCIAL <br />O~ O~ ST~U~; ~l <br /> <br /> ~BASE FEE <br /> A. RESIDEIqTD~L <br /> <br /> Single Family or multi-Family per <br /> dwelling unit (each fixture) <br /> New construction <br /> Alter~tions <br /> Re-located structure <br /> <br /> Water Lines <br /> First 100 ff. or fraction thereof <br /> For additional 100 ff. (up to <br /> maximum orS00 feet) <br /> <br /> Sewer Lines <br /> First I00 feet or fi.action thereof <br /> For additional 100 feet (up to <br /> maximum 500 feet) <br /> <br />B. COIvl/VlERCL,~L (each fixture) <br /> <br /> New construction <br /> Alterations <br /> Re-located structure <br /> <br /> Water Lines <br /> Fkst 100 feet or fi.act/on thereof <br /> For additiorml 1 O0 feet <br /> <br /> Sewer Lines <br /> First 100 feet or fraction thereof <br /> For additional 100 feet <br /> <br />C. LAWN' SPRINKLER SYSTEM <br /> <br />Th¢iaatallafi°nisb¢ingmad¢°npr°perCyI°wnwhiehisn°tinteadedf°rmle' I <br />lease, or ~nt, <br /> <br /> 3. PLAN REVIEW SECTION <br /> <br /> Each protoctive backflow device <br /> <br />D. OTHER (as required by OSPSC a_qd <br /> Building Official) <br /> <br />NO. XFEE 'SUM <br /> <br /> $20,00 <br /> <br />--.$ 9,00 ...... <br /> $ 9,00 <br />__.5; 4.50__ <br /> <br />$2o.oo, ~ .' <br /> <br />--$15,00~ <br /> <br />--$30.00 <br /> <br />.... $15,0(L_._._ <br /> <br /> $ 9.00__ <br />.... $ 9.00 .... <br />__$ 9,00__ <br /> <br />~$20.00-,, <br />~$15,00 ..... <br /> <br />__$30.00 <br />~$15.00 <br /> <br />4,50 .... <br /> <br />We will provide plan review service if you complete Section <br />5B and submit two (2) sets ofpla~s and specifications with <br />this application. <br /> <br />This optional plan review program does not suspend the <br />required submission ofplans~ and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 33, <br /> <br />C lJ-45 <br /> <br />Rev. 2/92 <br /> <br />5. FEES Al. Enter total of fees from Sec, # 4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br /> Subtotal <br />B. Enter 25% ofllne A1 for Plan Review <br /> C, (.25 x Al) if required <br /> Investigation Fee(if re~l. ulr <br /> <br /> TOTAL AMOUNT DUE <br /> Receipt No.~~/~ l/3~ <br /> <br />$ <br />$ <br />$ ~ <br /> <br /> <br />