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BUILDING INSPECTION DIVISION <br /> 31 §O LANCASTER DR NE - SUITE C PERMIT NO <br /> FOR CITY VALIDATION SALEM OREGON 97305-1398 <br /> <br />~a ~t~ n ~ ~ d ~ O~te:PhoueS~-St47 8:00am*4:30pm <br /> <br />F~L~m~ PE~mT A~fiCA~ON Y ~ --~ -- <br />/ I 4. F~ SCH~ (~mplete and enter tomlinAl be~w) <br /> I m~se complete ~1 ~tions, 1 through 5 [ <br /> <br />1. LOCATION' OF INSTALLATION <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Ma/ling Addreas <br /> <br />Plumbing Board: <br /> <br />Contractor's Board Reg. No. <br /> <br />Job No. <br /> <br />%ng,,th,.,.. d.I <br />Agent's Signature: <br /> <br />3. PLANRBVIBW 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, 1/96 <br /> <br />USE OF STRUCTURB: <br />NEW/2 ALTERATION [] ADDITION E] RELOCATION <br /> <br />BASE FEE - <br />RESIDENTIAl(each ft?ure)~ <br />Aurora DweHiirg4qambmg'~e <br /> <br />Single Family or multi-family per <br />dwelling unit <br /> New ~onstrucfion <br /> <br /> Reconnect <br /> <br /> Modular Struotur¢ <br /> <br />10.oo <br /> <br /> 5.0O <br /> <br />Water Lines <br /> <br /> maximum of 500 fl,) $15.00 <br /> <br />First t0/3 fl, or fraction thereof $25.00 -. <br />For es, addnl' 100 fl. <br /> $15.00 -- <br /> <br />$15.00 -- <br /> <br />PROTECTIVE BACKFLOW DEVICE <br />Law~ vafumn breaker (sprinkler system) $ 4.50 <br />All others $10.00 <br /> <br />OTHI~R (as tequired by OSP3C <br /> and Building Ol~cial) -- <br /> <br /> A 1. Enter w~l of fees from <br /> ~. A~ 5% sgha~ (.05 x Al) ~ ~ , <br /> ~ ~ - ~ Subtotal $. <br /> <br /> B, ~r 25~ of I~e A1 ~or PI~ Review <br /> (Al + .25), if ~ui~ $ <br /> C. lnvestign~on Fee (if~qui~d) <br /> D, Rei.pection Fee (~5..) <br /> <br /> <br />