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FOR CITY VAIJDATION[ <br />Re~elved by: <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St NE · Room 132 <br /> Salem, OR 97301 <br /> <br /> 24 hr. lnsl~:lton Line 373=4427 <br />Offke: Phone 588-5147 8:00am - 4:30pm <br />FAX: 588-7948 <br /> <br />PLUMBING PERMIT APPLICATION <br />Please complete all ~ections, I through <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />PI~RMITS ARE NON-TRAHS~=RABLE AND EXPIRE IF WORK IS NOT I <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS, <br /> <br /> FOR OW'N'~R I~5TALLATIONS <br />Prope~y Owner (~leaso ptlat) <br /> <br />City~dtate..Zlp '-n <br /> <br />O~ner'a Sis~atu~: <br />Ag~t', S~nature: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />4. FEE SCHI]DULI] (C~npl~le snd enter Iolal in Al below) <br /> <br /> RBSlDENTIAL [] COMMI~CIAL <br /> USE OF STRUCTURe: <br /> NEW O AL'rm~,ATION Q ADDITION I~ R~LOCATION <br /> <br /> No. X Fm ~, ~um <br />BASE FEE <br /> <br />RI~mRNTIAL (each f~) <br /> A~m ~el~ ~bi~ F~ <br /> <br />~olli~ unit <br /> <br /> Al~m $10~ <br /> R~t $ <br /> Rel~at~ S~ $ 5~ <br /> ~lar S~cm~ $ <br /> <br /> ~t 1~ ~ or f~ct~n <br /> ~r ~1' 1~ ~ (up to <br /> ~ o~ fi.) $15.~ <br /> <br />CO~RC~ (~ch ~) <br /> <br /> N~ ~ct~ $10~ <br /> Al~t~ $10~ <br /> R~t $10~ <br /> <br />Sanitary & Su~t~ Lia~ <br /> F'u'at 100 ft. or f~ction thereof <br /> For addnl' 100 fl. <br /> <br />PROTECTIVE BACKPLOW DEVICE <br /> Latin vacuum breaker (spt"~nkler <br /> All othea's <br /> <br />OTHER (asa~qulivdbyO..VPSC <br /> and l~d~ng Ol~cia0 <br /> <br />$4.50 -- <br />$10.00 -- <br /> <br />DWELLINO PERMIT LABEL # of Labzh N/C <br /> <br />3. PLANRII~HW 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 /> <br />MC 15-45 <br />Rev. 1196 <br /> <br />Al. En~r to~ of fee~ from Sec. ~4 <br />A2. Add 5% surcharge (.05 x A 1) <br /> <br />~tbtotal <br /> <br />B. Ente~ 25% of line Al for Plan Revinw <br /> (A I * .25), if t~:luired <br />C. Investigation Fee {i f required) <br />D. Reimpeetion Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br />Receipt No. <br /> <br /> <br />