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'~FOR CITY VALIDATION [ <br /> [Received By: <br />[Date: <br /> <br /> MARION COUNTY <br />BUILDING INSPECTION DMSION <br />31 $0 L~e*~t~' Dr. NE - Suite C <br /> Salem, On."~on 97~0~-139S <br /> <br /> 24 HR Inspection Line 373-4427 <br />Office: phone ~8~=$147 8:00am - 4:30pm <br />FAX S8~-7948 <br /> <br />IPLUMBING PERMIT APPLICATION <br /> Please complete all Sections, 1 through 5 <br /> <br />1. LOCATION OF INSTAI.LATION <br /> <br /> S 151 1 1-13171 1-1/ <br /> <br />p~ ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT ] <br /> STAk'i ED WIT'rHN 180 DAYS OF ISSUANC~ OR IF <br /> WORK IS SUSPI~rDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />plumb~g-C~tramor Judson's, Inc. <br /> <br /> c~v Salem <br /> <br />' 81716 0 <br /> <br />MaainS <br />Addr~ P.O. BOX 12669 <br /> <br />tAX s 031-3 <br />PLUMBING BOARD NO. <br /> <br />CONTRACTOR~ BOARD <br />REGISTRATION NO. <br /> <br />JOUKNEYMANS <br />PLUMBERS NO. <br /> <br />CONTRACTOR'S SIGNATURE <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />Pmpmy Own= {plea*e <br />Mailing Address <br /> <br />City, State, Zip <br /> <br /> O~am-'s Signatu~ <br /> <br /> Agent's Sisna 'm~ <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 SB and submit two (2) sets of plans and <br /> specifications wit~ this application. <br /> <br />MC 13-43 7/97 <br /> <br />Dat~: <br /> <br />Issued by: <br /> <br />4. FEE SCHEDULE {Comple~ and en~r total in 5-Al below) <br /> <br />RESIDENTIAL ~ COMMERCIAL [~ USE: <br /> N~W f"l AL'rSKATION {~] .,J3DmONL,~ RE. OCATION ['"1 <br />BASE FEE Asscsscd on ~11 epplicati~s S20.00 <br /> ~ion: Wam'/Sewer Linc Appllc~ions w/no fixtmea) <br /> <br />~ OTY OTY <br />AREA DRAI~ INTERCF~°TOR <br />BACKFLOW pR~V DE%qCE LAUNDRY TUB <br />BATHTUB RECEPTOR <br />BIDET SHOWER <br />CATCH BASIN ~ SINK <br />CLOTHES WASHER TROUGH DRAIN~ <br /> <br />FLOOR DRAIN WATER <br />OTHER WET BAR <br /> <br />Lawn vacuum b~ker / s~nkl~r symm __ x ~4.$0 - $ <br /> <br /> l~idonti~l: Fir~10Ofc. orfracfionflu~of __ x$20.00 <br /> For ~a addnl 100 ft Up to ~00 fe~t __ x $I~.00 <br /> Comm~cial: Fire 100 fi. Or fratrfion ~ho'onf x ~25.00 = 5 <br /> For ea~lal lOOf~ x51~.O0 =S <br /> <br /> Re~inmial: First 100fl. orfra~ionth~of x530.00 ~5 <br /> Fore~utdnl IO0tLUpto$00 f~,.~ __ xSl$.00 -5__ <br /> Commercial: FLm 100 fi- Or fraction the~of x $30.00 = <br /> Fo~ e~ ~lnl 100 feet x 51~.00 <br /> <br /> Re~id~hfl: Fire 100 fi- Or framlon tl~.reof x 530.00 <br /> For ~ addn1100 fi- Up to 500 f~ __ <br /> Coram~dal: For 100 tL or fra~'don ~of z 530.00 <br /> Fore,rial 100 f~t xSl~.OO =5 <br /> <br /> MINOR INSTALLATION I.,~ELS ~ ,t~,~ 5 · <br /> (Pack of 10 labels I~,~ ~ ~old only ~o Plumbing ~mra~or~) <br /> <br /> ~ # of <br /> (For N~w Single F,rally Dv~llin~ Only) <br /> <br />5. FEES <br /> <br />No. <br /> <br />Svbmt~ <br /> <br />TOTAL AMOD-NT DUE <br /> <br /> <br />