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FOR CITY VALIDATION <br />Received by.' <br />Dato: <br /> <br />COMMUNITY DEVELOPMENT CENTER PERMIT NO: _ _ <br /> <br />285 Church St NE * Room 132 <br />Salem, OR 97301 <br /> <br /> 24 hr. Inspection Line 373-4427 <br />Offlee: Phone 588~147 8:00am - 4:30pm <br />FAX: 588-7948 <br /> <br />MECHANICAL PERMIT APPLICATION <br />Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />PERMITS ARE NON-TRAHSFERABLE AND EXPIRE IF WORK IS NOT <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPEI~DED FOR 180 DAYS. <br /> <br />2A. COHTRACTOR INSTALLATION ONLY <br /> <br />MailingA~dreas "~-k~kG O~aE~ ~-~q~'Yl [~63C ~r~.~ <br />Contractor s Licmse No. ~ ~ ~ ~O% <br /> <br />~oatractor's Board Reg~~ Job No. <br /> <br />2B. FOR OWN'ER INSTALLATIONS <br /> <br />Pmpeay Owner (ple~eprim) <br /> <br />Mailing Addr~s <br /> <br /> City/State/Zip <br /> Ow~r's Signature: <br /> Agent's Signature: <br /> <br /> 3. PLAN REVIEW SECTION <br /> <br /> Marion County does not require a plan review. <br />I We will provide plan review service if you complete <br />I Section 5B and submit two (2) sets of plans and <br />I specifications with this application. <br /> MC 1541 <br /> REV 8~96 <br /> <br />Date: <br />Issued by: ,-- <br /> <br />4. l~l~ SCHEDULE (Complete and onto' total ia,~below) <br /> <br /> REStDEiVrIAL 121 ¢OMMERC~:I~ [21 ..~ <br /> USE OF STRUCTURE: <br /> NEW D ALTERATION D ADDITION ~ RELOCATIO~I <br /> <br />GAS ~1 or ELECTRIC <br />BASE FEE <br /> <br />No. X <br /> <br />FORCED AIR FURNACE <br /> up to 100,000 BTU <br /> over 100,000 BTU <br /> <br /> under 3 Ton <br /> 3 Ton and up <br /> <br />AIR COIX~ITIOIX~R under 3 Ton <br /> <br />Commercial / Industrial lnci~ralor <br /> <br />ADDITIONAL APPLIANCES Gas Water Heater <br /> Gas Log Lighter <br /> Gas Barbeque <br /> <br />GAS PIPING SYSTEM <br /> 14 outlets (per outleO <br /> 4 and up outlets (per oufleO <br /> <br />Applianoe Vents not ia¢luded in <br />~ appliance permit <br /> <br />OTHER (as required by Build~s{g Ol~cial) <br /> <br />DWELLING PERMIT LABEL # of Lab~h <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 />$4,50 -- <br />$ 4.50 -- <br /> <br />$ 3.00 -- <br />$ 3.~0 <br />$ 7.50 <br />$ 7.5O <br />$30.00 <br /> <br />$ 7.50 <br />$7.50 <br />$ 7.50 -- <br />$ 7.50 <br /> <br />$ 2.00 __ <br />$ .50 __ <br /> <br />$ 3.00 -- <br /> <br />N/C <br /> <br />5. FEES <br />Al, Enter totalof fe~s from Sec. ~ $__ <br />A2. Add 5% surcharge (.05 x Al) $ <br />Subtotal <br /> <br /> B. Enter 25% of liae A1 for Plan Review <br /> (Al + .25), if r~quired <br /> C. Investigation Fee (if required) <br /> D. Reinspecfion Fee ($25.00) $ ~ ~..~_~ <br /> TOTAL AMOONT DUE <br /> Receipt No. <br /> <br /> <br />