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FOR CITY VALIDATION[ <br />Reoeiwd by:. <br />Date: <br /> <br />MECHANICAL PERMIT APPLICATION <br />Ple~e complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />Crois S~eet/Direndom: ~l .~"~'~-J~ <br /> <br />~ A~ ~O~-~S~B~ ~ ~ ~ WO~ IS NOT <br /> ~ ~ 1 ~ DAYS OP ISSU~ OR ~ <br /> ~ ~ S~D~ ~R i~ DAYS. <br /> <br />~ CO~OR ~L~ON O~Y <br /> / <br /> <br />~'a ~a~ ~. No. Job No. <br /> <br />liB. FOR OWHi~R IlqSTALLATIONS <br /> <br />Mailing Addre~ Phone <br />City/State, Zip <br />Owner's Sign~me: <br />Agent's Signature: <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St NE · Room 132 PERMIT NO: <br />Salem, OR 97301 Date: jf / t~ ~ ~. <br />~4 br. [nspecFA~ottd';::?5-4427 '~uod by: <br />Office: Phone S88-S147 8:00am - 4:30pm <br /> <br /> 4. lq~ SCI'~UL~ (Complete and ente~ tolal in Al below) <br /> <br /> RESIDF_2qTIAL C-I COMMERCLa, L C~ <br /> USE OF STRUCTURE: <br /> NEW rn ALTERATION O ADDITION Ci RELOCATION <br /> GAS O or ELECTRIC O <br /> No. X F~ = Sum <br /> BASE PEF. $10.00 <br /> <br />FORCED AIR FURNACE <br /> up to 100.000 BTU <br /> over 100,000 BTU <br /> <br />Floor Furnace <br />Suapended Heater <br />Wall Heater <br />Fleor Mconted Heater <br /> <br />H~AT PUMP <br /> trader 3 Ton <br /> 3 Ton nnd up <br /> <br />AIR <br /> under 3 Ton <br /> 3 Tonand up <br /> <br /> and Dryer Veins <br /> <br />Wood Stove/Fireplace <br /> <br />6.00 <br />7.00 <br /> <br />$ 6.00 <br />$ 6.00 <br />$ 6.00 <br />$ 6.00 <br /> <br />$ 6.50 <br />$11.00 <br /> <br />$ 6.50 <br />$11.00 <br /> <br />$4.50 __ <br />$4.50 <br />$4.~0 -- <br />$4.5O -- <br /> <br />$ 3.OO -- <br />$7.~o __ <br />$7.50 -- <br />$30.00 -- <br /> <br />ADDITIONAL APPLIANCB8 <br /> <br /> Gas Log Lighter <br /> Gas Bad~eque <br /> O~her <br /> <br />OAS PIPINO SYSTEM <br /> 1-4 outlets (per outlet) <br /> 4 and up cutle~s (per outlet) <br /> <br />OTHER (as r~ir~d by Build~g 01~ciaO <br /> <br />DWELLINO PERMIT LABEL # of Labels <br /> <br />$ 7.~0 <br />$7.~0 -- <br />$ 7.~0 -- <br />$ 7.~0 -- <br /> <br />$ 2.00 <br />$ .5o <br /> <br />$ 3.00 <br /> <br />3. PLANP..EVIBW 8IICTION <br /> <br />Madon 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 1541 <br />REV 8/96 <br /> <br />5. FEllS <br />Al. Enl~r lotsl of fees from Sec. ~4 $.__ <br />A2. Add 5% sm-charge (.05 x Al) $.__ <br /> ~bt~l $.~ <br /> <br /> B. ~r 25~ ofl~eAl forP~view <br /> (Al + .25~ if~d $.__ <br /> C. ~v~a~ Fee (if~u~d) $.__ <br /> D. Re~p~t~n ~ ($25.~) $.~ <br /> <br /> T~ ~O~ D~ <br /> R~eipt No. <br /> <br /> <br />