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IFOR OFFICE USE ONLY MARION COUNTY BUILDING INSPECTION <br />Received by: 220 High Slxect NE <br />Date: Salem, Oregon 97301 <br /> <br /> PLUMBING PERMIT APPLICATION ] COda~k~?::::'7$9841~7904 Date' <br /> P/ease complete all Sections, 1 through 5 ~ '~,'~~ ~,~ '.. <br /> <br /> I ~CATION OF IN~ALLATION ~ ~ ' <br /> <br /> BASE FEE $20.00 <br /> A. RESIDE~L <br /> <br />PERMrI'S ARE NON-TRANSFERABLE AND NON-REFLrNDABLE AND <br />t X ' RI ,' WORK IS NOT STARTED wITIqIN 180 DAYS OF ISSUANCE <br />OR IF WORK IS SUSPENDED FOR. 180 DAYS. <br /> <br />2A, CONTRACTOR INSTALLATION ONLY <br /> <br />JoumeymaWs Plumber~ No, 4~' ? 5- Jlv <br />lB, FOR OWN 1~3R INSTALLATIONS <br /> <br />Mailing Address I Phone <br /> <br />The installatio a is being made on propexty I own which is not intruded for scl*, <br /> <br />Owners Sigllatut'e <br /> <br /> PLAN REVIEW SECTION <br /> <br />We will provide plan review service if you complete Section <br />5B and submit two (2) sets of plans and specifications with <br />this application, <br /> <br />This optional plan review prograra does not suspend the <br />required submission &plans, and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 53. <br /> <br /> ,'[(7 I5-45 <br />Rev. 7/92 <br /> <br />Single Family or multi-Family per <br />dwelling unit (each fixture) <br /> New construction <br /> Alterations <br /> Re-located slxucture <br /> <br />Water Lines <br /> First 100 ff. or fraction thereof <br /> For addiriona1100 ff. (up to <br /> maximum orS00 feet) <br /> <br />Sewer Lines <br /> First 100 feet or fraction thereof <br /> For additional 100 feet (up to <br /> maximum 500 feet) <br /> <br />B, COMMERCIAL (each fixture) <br /> <br />New constXuctidn <br />Alterations <br />Re-located structure <br /> <br />Water Lines <br /> First 100 feet or fraction thereof <br /> For additional 100 feet <br /> <br />Sewer Lines <br /> First 100 feet or fraction thereof <br /> For additional I00 feet <br /> <br />LAWN SPRINKLER SYSTEM <br /> <br />~ach protective backflow device <br /> <br />OTHER (as regdired by OSPSC and <br />Building Official) <br /> <br /> --$ %00 <br /> --$ 9.00 <br /> __$4,50 <br /> <br /> __$20.00.~ <br /> <br /> --$15,00 <br /> <br />__$30.00 <br />__$15.0o <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 />--$4.50 <br /> <br /> 5, FEES Al. Enter total &fees from Sec, # 4 <br /> A2, Add 5% surcharge COS x Al) <br /> <br /> Subtotal <br /> B. Enter 25% of line A1 for Plan Review <br /> (.25 x Al) i,f, reqdired <br /> C. Investigation l;ee(ifrequired) <br /> D, Reinslx~tion Fee <br /> <br /> TOTAL AMOUNT D'~JE <br /> <br />[ Rece pt No, ,, <br /> <br />$ <br /> <br />$ <br />$ <br />$ <br /> <br /> <br />