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Ct <br />~ 1 BUILDING INSPECTION DIVISION PERMIT NO: <br />IFOR CITY VALIDATION/ 315o Lancaster Dr, ~- Suite C <br /> <br /> Salem O <br />R<eived By: ~ Date:~ <br />~ I~~: ~pm Issued by: __ <br /> <br />I MfiOHANIOALPERMITAPPLIOAIION ] ~ 4. mESC~DULE(Co~p~t~d~nte~totalinA~ow) <br />I Please complete all Sections, ~ through 5 u km0u c0u co~ca[ m us :_ _ <br /> <br /> 1. LOCATION OF ~STALLA~ON u~---- nAS 0 mECm~C ~ <br /> ~ASE ~E ASSESSED ON ALL APPLICATIONS $10.~ <br /> <br />TAX ACCOUNT NO. <br /> <br />JOB ADDRESS <br /> <br />PROPERTY OWNE ! /~. ~' ~-~ iA ~ <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> Property Owner (please print) <br /> <br /> Mailing Address <br /> <br /> City, Sta~, Zip <br /> <br /> Agent's Signature <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 />FURNACE OTY <br />FORCEDAIRUPTO 100.0~OBTU x $6.~0 =$ -- <br />FORCED AIR OVER J00.~O0 BTU x $7.~0 = $ -- <br />FLOOR HJRNACE x $6.00 = $ __ <br />DUCTS (ALTERATION/EXTENSION) x $7.50 =$ __ <br />GAS INSTALLATIONS <br />GAS FURNACE (up to 100.~OOBTU) x $6.00 =$ -- <br />GAS FURNACE (over l00.0OO BTU) x $7.00 =$__ <br />GAS HREPLACEflNSERT x $7.50 = $ -- <br />GAS WATER HEATER x $7.50 = $ __ <br />GAS LOG LIGHTER x $7.50 = $ __ <br />GAS BARBEQUE x $7.50 -- $ __ <br />GAS PIPING <br />Each outlet ap to 4 outlets x $2.00 = $ __ <br />Each additional outlet over 4 outlets x $.50 = $ -- <br /> <br />WOODSTOVE LmE?L.'.~E ~ I ~' t~/~l.~ x $7.50 = $ <br /> <br />5. FEES <br /> Al. En~r total of fees from Sec. <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br />B. Enter 25% of line A1 for Plan Review <br /> (Al + .25). if required <br />C. Investigation Fee (if requked) <br />D. Re[nspection Fee ($25.00) <br /> <br />Receipt No. <br /> <br />TOTAL ,auMOUNT DUE <br /> <br />MC 15-41 7/97 <br /> <br /> <br />