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FOR CITY VALIDATION <br />Reoeivedby: <br />Date: <br /> <br />MARION COUNTY BUILDEq'G 'NSPECTION~]~(~]-~ <br /> COMMUNITY DEVELOPMENT CENTER n=o~t~,~.'~/ <br /> 2SS Church St NE' Room 132 r'-"'~ll'a~-' <br /> Salem, OR 97301 ¢.~. e~ <br /> Date: <br /> <br /> 24 Rr/n,q,~oa r.h.= sss-'r9o¢ MARION COUNTY <br /> ok: sss-sx4? s:0Oa.m.-4:aep.m. Issued b~iiiLDiNG <br /> iN~H~'U I IUN <br /> FAX: 588-7948 <br /> <br />MECHANICAL 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 /> I <br /> STARTED V~YH IN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. COlqTRACTOR INSTALLATION ONLY <br /> <br /> O OWX' X INST ^T O-NS ' - <br /> <br />Property Owner (ple~soprint) <br />Mailing Address Phone <br />City/Stag/TAp <br /> <br />Agent's Sigaamre: <br /> <br />4. FEE SCHBDULE (Complete and ente~ totalin Al below) <br /> <br /> RESIDENTIAL ,~ iCOMMERCIAL <br /> USE OF STRUCTURE: <br /> NEW O ALTERATION ~ ADDITION [~RRL-'O12ATION <br /> GAS [21 or ELECTRIC ~ <br /> No. X Feo = Sum <br />BASE FEE $10.00 <br /> <br />5.50 <br /> <br />N/C <br /> <br />ADDITIONAL, APPLIANCES <br />Gas Water Heater $ 7,50 <br />Gas Log Lighter $ 7.50 -- <br />Gas Barb¢qu¢ $ 7.50 -- <br />Other $ 7,50 -- <br /> <br />GAS PIPING SYSTEM <br /> 14 outlets (per outlet) <br /> 4 and up outlets (p~r outlet) <br /> <br />Appliance Vents not included in <br />an appliance permit <br /> <br />OTHER (as required by Builddng Ol~cial) <br /> <br />DWELLING pERMIT LABEL # of Labels <br /> <br />$ .50 <br /> <br />$ 3.00 <br /> <br /> 3. PLAN REVIEW SECTION <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 />MC 1541 <br />Rev. 12/94 <br /> <br />5. FEES <br /> A L Enter total of fees flora Sec. <br /> A2. Add 5% sumlutrge (.05 x Al) <br /> <br />~abtotal <br /> <br />B. Enler 25% ofli~ Pti forplan Review <br /> (Al + .25), if required $__ <br />C. Investigation Fee (if required) $__ <br />D. Reinspeetion Foe ($25.00) $__ <br /> o,..rr ,/7.33 <br />Receipt No, <br /> <br /> <br />