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MARION COUNTY <br /> <br /> 'l BUILDING INSPECTION DIVISION PERMIT NO: <br /> TY VALIDATIONI 315o L~¢~t~ ~r. ~- S,it~ C <br />IReceived By ~ Salem, Oregon 97305-1398 <br /> : Date: <br />IDate: ~l 24 HR Inspection Line 373-4427 <br /> Office: phone 588-5147 8:00am - 4:30pm Issued by: <br /> FAX ~8-7948 ---- <br /> <br />L H/ea$' c~°m~°l"S ali o'~IlO"'~' I Ir/r°" 0~997 4. FEE SCHEDU_~.(_ ~ , to.lln S-Al below)_. <br /> RESIDENTIAL ~'. COMMERCIAL ~ USE:__ <br /> 1. LOCATION OF INSTALLATION ~]ARI0~ C00NT¥ "'-~7 <br /> ~ ..-Z'i.--2' .-~-~ NEW ~'~ ALTERATION ~ ADDITION ~ RELOCATION <br /> £~TI <br /> TAX <br /> ACCOUNT <br /> NO. <br /> ~BASE FEE Assessed on all applications $20.00 <br /> lOB ADDRESS ~ j /~/~ '~ (Exception: Water/Sewer Line Applications w/no fixates) <br /> <br /> PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br /> Plumbing Contractor <br /> <br />Mailing <br />Address <br /> <br />PLUMBING BOARD NO. <br /> <br />CONTRACTORS BOARD <br />REGISTRATION NO. <br />JOURN~Y3/L6aNS <br />PLUMBERS NO. <br /> <br />CONTRACTOR'S SIGNATURE <br /> <br />2B. FOR OVv~ER INSTALLATIONS <br /> <br />Mailing Address~~. / <br />City, State, Zip ~d~ <br /> <br /> Agent's Signat~r~ <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 /> <br />FIXTURES OYY <br />AREA DRAIN INTERCEPTOR <br />BACKFLOW PREV DEVICE LAUNDRY TUB <br />BATHTUB RECEPTOR <br />BIDET SHOWER <br />CATCH BASIN SINK <br />CLOTHES WASHER TROUGH DRAIN -- <br />DENTAL UNIT TUB/SHOWER <br />CUSPIDOR URINAL <br />DRINKING FOUNTAIN WATER CLOSET <br />FLOOR DRAIN WATER HEATER -- <br />OTHER WET BAR <br /> <br />OTY <br /> <br /> Total # Fixtures x $10.00 = $ <br />Lawn vacuum breaker/sprinkler system ~ x $4.50 = $ <br /> <br /> Residential: First l00 ft., Or fracrion thereof __ x$20.00 <br /> Foreaaddnll00ftUpto5~0feet __ x$15,00 =$__ <br /> Commercial: First 100 fl, Or fraction thereof __ x $25.00 = $__ <br /> For ea addn1100 feet x $15.00 = <br /> <br /> Residential: First 100 f. Or fraction thereof __ x $30.00 = <br /> ForeaaddnllOOfl. Upto5OOfect __ x$15.00 =$__ <br /> Commeralah First 100ft. Or fraction thereof -- x$30.00 =$__ <br /> For ea addnl 100 feet x $15.00 = $ __ <br /> <br /> Residential: FirstlOOfi. Or fraction thereof -- x$30.00 <br /> For ea addn1100 fi. Up to 500 feet __ x $15.00 <br /> Commercial: For lO0~.Orfractionthcrcof -- x$30.00 =$__ <br /> Foreaaddnl 100 feet -- x$15.00.~,$ <br />MINOR INSTALLATION LAftELS x $50.00 = $ -- <br />(Pack of 10 labels ~ $5.00 each, sold only to Plumbing contractors) <br /> <br />~ # of Labels N/C <br /> <br />5. FEES <br /> A I. Enter total of fees from Sec, #4 $ ~ <br /> A2. Add 5% surcharge (.05 x Al) $~ . <br /> B. Enter 25% of lin* A I for Plan Revi~w~ ,~..~ <br /> (At + ,25), if required -- / $ <br /> C. Investigation Fee (if required) $ <br /> D. Re[nspeetion Fee ($25.00) $ <br /> Receipt No.~ <br /> <br />MC 15-45 7/97 <br /> <br /> <br />