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FOR CITY VALIDATIONI <br />Received by: <br />Date: <br /> <br />285 Church St NE · Room 132 <br />Salem, OR 97301 <br /> <br />24 Hr Inspection Line: 588-7904 <br />Office: 588-5147 8:00 a.m. - 4:30 p.m. <br />FAX: 588-7948 <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />IPLUMBING PERMIT APPLICATION <br />Please complete all Sections, I through <br /> <br /> 1. LOCATION OF INSTALLATION <br /> <br />PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br />STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Pithing Board: <br /> <br />Contractor's Board Reg. No. <br /> <br />/ob No. <br /> <br />1oumeyman's Plumbers No. <br /> <br />Contractor's Signature: <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />Pwperty Owner (please print) <br /> <br />Mailing Address <br /> <br />City/State/Zip <br /> <br />Owner's Signature: <br /> <br />Agent's Signature: <br /> <br />3. PLAN REVIEW SECTION <br /> <br />Phone <br /> <br />4. FBB SCHI~DULE (Complete and enter total in A1 below) <br /> <br /> RBSIDEN'HAL IZI COMMERCIAL [] <br /> USE OF STRUCTURE: <br /> NEW I~1 ALTERATION I~ ADDITION ~ RELOCATION <br /> <br />BASE FEE <br /> <br />RESIDENTIAL (each fixture) <br /> Aurora Dwelling Plumbing Fee <br /> <br />Single Family or multi-fa~nily per <br />dwelling unit <br /> New construction <br /> Alterations <br /> Reconnect <br /> Relocated Structure <br /> Modular Structure <br /> <br />Water Lines <br /> First 100 ft. or fraction thereof <br /> For ea. addnl' 100 ft. (up to <br /> maximum of 500 ft.) <br /> <br />Sanitary & Storm Lines <br /> First 100 fl. or fraction thereof <br /> For addnl' 100 ft. (up to <br /> maximum of 500 ft.) <br /> <br /> No. X Fm (=$2~0x/ <br /> <br />~q. ft. x $.065 = ~ <br /> <br /> ~ $~o.oo <br /> ~,~-./~,~- $~o.oo <br /> <br /> $2o.~ <br /> <br /> $~.~ <br /> <br /> $10.~ <br /> $1o.~ <br /> $1o.~ <br /> <br /> $~ .~ <br /> <br /> $15.~ <br /> <br /> $~.~ <br /> <br /> $15.~ <br /> <br /> $4.~ <br /> $10.~ <br /> <br />COMMERCIAL (each fixture) <br /> <br />New construction <br />Alterations <br />Reconnect <br /> <br />Water Lines <br /> First 100 fi. or fraction thereof <br /> For ea. addni' 100 fi. <br /> <br />Sanitary & Storm Lines <br /> First 100 fl. or fraction thereof <br /> For addnl' 100 fl. <br /> <br />PROTECTIVE BACKFLOW DEVICE <br /> Lawn vacuum breaker (sprinkler system) <br /> All others <br /> <br />OTHER (as required by OSPSC <br /> and Building Ot~cial) <br /> <br />DWELLING PERMIT LABEL # of Labels <br /> <br />N/C <br /> <br />Marion County does not require a plan review. <br />We will provide plan review service if you complete <br />Section 5B and submit two (2) sets of plans and <br />specifications with this application. <br /> <br />MC 1545 <br /> <br />5. FEES <br /> Al. Enter total of fees from Sec. #4 <br /> A2. Add 5% snreharge (.05 x Al) <br /> Subtotal <br /> <br /> B. Enter 25% of line Al for Plan Review <br /> (Al + .25), if required <br /> C. Investigation Fee (if required) <br /> D. Reinspection Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> Receipt No. <br /> <br />$ <br />$ <br />$ <br /> <br />$ <br />$.~ <br /> <br />S .":",t <br /> <br /> <br />