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I <br />FOR OFFICE USE ONLY] <br />Received by: <br />Date; <br /> <br />PLUMBING PERMIT APPLICATION <br />Please complete all Sections, I through 5 <br /> <br /> 1, LO~ATION OF INSTALLATION.. <br /> <br />lob Addtess <br />City I Cross gL <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> 220 High Street NE <br /> Salem, Oregon 97301 <br /> <br /> Phone 588-5147 8:00 a-m, ~4:30p,m, $1T~ #: <br /> Code-A-Phone: 588-7904 <br /> FAX: 588-7948 Date: <br /> <br /> 4. FEE sc]a~Dm~E <br /> <br />'i <br /> <br />PERMYIX3 ARE NON-TRANSFERABLE AND NON-P, EFUNDABLI~ AND <br />EXPIRE IF WO]g.K IS NOT STARTED WITHIN lg0 DAYS OF ISSUANCE <br />OK IF WORK IS SUSPENDlgD FOR lB0 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Mail~ns Addres~ <br /> I ' <br />?rop¢~y Ow*er Phonei <br /> <br />Plumbing Boa~J: I <br /> I ' <br />Contractors Board Reg. No. lob No. <br /> <br />Joumeyman':¢ Plumbers No, <br /> <br />Contractor's Signature: <br /> <br /> ~B. FOR OWNER INSTALLATIONS <br /> <br />Pmpeay Owner i <br />Ma)llas Addm~* Phone] <br /> <br />Citg/State/Zip <br /> <br />TB~ installation i.q being made on property I own which is not intended for sale, <br /> <br />lease, ortent. ~ ~ ] <br />Ownees Signatm'e .X. k~ i <br /> <br />3. PLAN REVIEW SECTION <br /> <br />We will provide plan review service if you complete Section <br />5B and submit two (2) $ets of plans and specfficatmqs with <br />this application. <br /> <br />This optional plan review program does not susPendithe <br />required sfibmission of plans, and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 53. <br /> <br />(C I5:45 <br />Rev, 7/92 <br /> <br />BASE FEE <br />A. P,,ESIDElqTI~L <br /> <br /> Single Family or multi-Family per <br /> dwelling unit (each fixture) <br /> New construction <br /> Alterations <br /> Re-located structure <br /> <br /> Water Lines <br /> First 100 ~. or fi.action thereof <br /> For additional 100 It (up to <br /> maximum of 500 feet) <br /> Sew& 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 eonstmeti6n <br /> Alterations <br /> Re-located structure <br /> <br /> Water Lines <br /> First 100 feet or fi.action thereof <br /> For additional 100 feet <br /> <br /> Sewer Lines <br /> First 100 feet or fraction thereof <br /> For additional 100 feet <br /> <br />C. LAWN SPRINKLER SYSTEM <br /> Each protective backflow device <br /> <br />D. OTHER (as reqdirefl by OSPSC and <br /> Building Officaal) <br /> <br />NO. XFEE =SUM <br /> <br /> $20.00 <br /> <br /> -- $ 9.00 <br /> --.$ 9.00 <br /> <br /> __$20.00 <br /> __$15.00 <br /> <br /> __$30.00 <br /> <br />__$15.0~ <br /> <br /> __$ 9.00__ <br /> --.$ 9,00 <br /> __.$ 9,00__ <br /> <br /> --.$20.00 . <br /> --.$15.oo <br /> <br /> __$30.00 <br /> __.$15.00 ......... <br /> <br /> --.$ 4.50 <br /> <br />5, FEES Al- Enter total of fo, es from Sec. # 4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br /> Subtotal <br />B. Enter 25% of line A1 for Plan Review <br /> (.25 x Al) if required <br /> C. Investigation Fee(i f required) <br /> D. R.einspeotion Fee <br /> <br /> TOTAL AMOUNT DUE <br /> Receipt No. , ,,, <br /> <br /> <br />