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, COMMUNITY DEVELOPMENT CENTER ~~ <br />FOR CITY AL. IDA ION[ Cm h St NS. oom 132 <br />Re~ved by:~ Salem, OR 97301 <br /> <br /> 24hr lnspeelton Line 373-4427 JUN ? 19 <br /> I <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />ARB NON-TRANSFeRABLE AND EXPIRE IF WORK IS NOT <br />frrARTED WITHIN 180 DAYS OF ]SSUANCE OR IF <br /> WORK IS SUSPI~IDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Plumbing Board: <br /> <br />Contractor's Board SoS. No. <br /> <br />Journeyman's Plumbers No. <br />ConUaclor'l Signature: <br /> <br />No. <br /> <br />2B. FOR OWNER INSTALI~ATION8 <br /> <br />As0nt's Si~nnmre: <br /> <br />US]~ OF STRUC'rI.~: ~ <br />NEW ~] ALTERATION G ADDmON ~ RELOCATION <br /> <br />BASB FEE <br /> <br />I~NTIAL, (each <br /> Amm'a Dwell{n{ Plumbing <br /> <br />Sk~k [~ily ~ ma~-f~y <br />~elli~ unit <br />N~ ~m~c~ $10.~ <br />~ $10.~ <br />~t <br /> <br /> ~1~ S~ $ <br />W~r ~ <br /> <br /> ~r~. n~l' I~ fi. (up <br /> ~ofS~ ~.) $15.~ <br /> <br /> ~r nd~' 1~ · (up ~ <br /> m~ ofS~ ~.) $15~ <br /> <br />COM~RCI~ (~h f~) <br /> <br /> N~ ~t~n $ <br /> A~m $10~ <br /> ~t $10~ <br /> <br />Wm~ <br /> <br /> ~em. ad~' 1~ fl. <br /> <br />SaniU~'y & S~rm Lines · <br /> Vnet 100 fL or fraction thereof ~ <br /> For nddnl' I00 ft. <br /> <br />$15.00 <br /> <br />$30.00 I <br /> <br />$15.00 ~ <br /> <br />PROTECTIVE BACKFLOW DEVICE <br />Lawn vacuum bmak~' (spdnkl~ lystem) __L_.~ $4.50 _.~) <br />All othecs $10.00 __ <br /> <br />OTHBR (as requir~dbyO~P~C and Bud~ing O~ial) <br /> <br />DWI{LLINO PERMIT LABEL # of <br /> <br />3. PLANRBVIBW SECTION <br /> <br />Marion County does not require a plan review. <br />We will provide plan review service if you complete <br />Section $B and submit two (2) sets of plans and <br />specifications with this application. <br /> <br />MC 15-45 <br />Rev. 1/96 <br /> <br />A I. Boter Iotal of foes ft~m S e~. <br /> <br />Add 5% surcharge 605 x Al) <br /> <br />(Al + .25), if required ~ ' ' <br />C. Investigation Fee (if required) <br />D. R~impeetion Fe~ ($2~.00) <br /> <br /> _ ~ _ TOTAL AMOUNT DUB <br />Receipt No, ~ <br /> <br /> <br />