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o,a omc[qs., <br />,Received by:~7<, 7 <br /> <br />MARION COUNTY BUILDING <br /> <br /> Salem, Oregon 97301 <br /> <br />Phone 588-5147 $:00a. m,~4:30p,m, <br />Code-A-Phone: 588-7904 <br /> FAX; $88-79417. <br /> <br />PLUMBING PERMIT APPLICATION <br />Please complete all Sections, 1 through 5 <br /> <br />Issued by: <br /> <br /> 1. LOCATION OF INgI~ALLATION <br />,o, /,-/6 $. <br /> <br />PEILMITS ARB NON-TRANSFERABLE AND NON-RElqJNDABLE AND <br />EXPIRE IF WORK IS NOT STARTED WITIIIN 18O OAYS OF ISSUANCE <br />OR IF Weak IS SUSPENDED FOR IS0 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br />Contractor I Phone ' <br />Mailing Address <br /> <br />Prurnblng Board: <br /> <br />Contra~tot'~ <br /> Board <br /> Reg. No, ] /ob No, <br /> <br /> 2B, FOR OWNER INSTALLATIONS <br /> <br />Owae~ Signature ~13 3, PLAN REVIEW SECTION <br /> <br />We will provide plan review service if you complet~ Section <br />5B and submit two (2) sets of plans and Specifications with <br />this application. <br /> <br />This optional plan review program does not suspend the <br />required submission &plans, and specifications when required <br />by the Oregon Structural Specialty Code, Chapter 53. <br /> <br />4. FEE SCHEDULE (Complete and enter total in Al below) <br /> [] RESIDENTIAL [~ COMMERCIAL <br /> use OF STRtJCIIJRE: [] <br /> ~W [2~T~UO~ [] ^Vr>mo~ [] ~'zoc^r~o~4 ~] <br /> <br /> BASE FEE <br /> A. RESIDENTIAL <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 ft. or fraction thereof <br /> For additional 100 ~. (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 /> max/mum 500 feet) <br /> <br /> B. COMMEKCIAL (each fixture) <br /> <br /> New consm~cti6n <br /> Alterations <br /> Ko-located s~ucture <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 <br /> <br /> C. LAWN SPRINKLER SYSTEM <br /> <br /> Each protective backflow device <br /> <br />D. OTHER (as required by OSPSC and <br /> Building Officfal) <br /> <br />NO, X FEE = SUM <br /> <br /> $20.00 <br /> <br /> "~ $ 9.00~ 7 <br /> --$ 9.00-- <br /> --$ 4,50 <br /> <br /> ( $20.00 Z° <br /> <br /> I $~0.00_~_e <br /> <br />__$ 9.00,. <br />--$ 9.00 <br />--$ 9.00, <br /> <br />--.$20.00 <br />--$15.00,, <br /> <br /> $3O.00__ <br />--$15.00 <br /> <br />--$ 4.50 <br /> <br />5. FEES <br /> Al. Eater tootal of fecs from Sec. # 4 <br /> A2.. Add 5~ surcharge (.05 x Al) <br /> <br /> Subtotal <br /> B. Enter 25% of line Al for Plan Review <br /> (.25 x Al) freqa red <br /> C. Investigation F~[ifrequired) <br /> D. RoinspectJon Fcc <br /> <br /> ,IJE <br />t, pt 73 7 <br /> <br />$ <br />$ <br />$ <br /> <br /> (CJ.5,45 .... <br />Rev. 7192 <br /> <br /> <br />