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FOR CITY VALIDATION <br />Received By: <br /> <br />Date: <br /> <br /> MARION COUNTY <br />BUILDING INSPECTION DIVISION <br /> 3150 Lancaster Dr, NE - Suite C <br /> Salem, Oregon 97305-1398 <br /> <br /> 24 HR Inspection Line 3734427 <br />Office: phone 588-5147 8:00am - 4:30pm <br />FAX 588-7948 <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br /> PLUMBING PERMIT APPLICATION <br /> Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />TAX ACCOUNT NO. <br />,O ADDRESS a_Ba src ' <br /> <br />CROSS ST[ET~I~CTIONS <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 />lPlumbing Contractor <br /> <br />4. FEE SCHEDULE (Complete and enter total in 5-Al below) <br />RESIDENTIAL I-I COMMERCIAL i"l USE: <br /> <br /> NEW ~ ALTERATION O ADDITION {~ RELOCATION {~ <br /> <br />BASE FEE Assessed on all applications $20.00 <br /> (Exception: Water/Sewer Line Applications w/no fixtures) <br /> <br />AREA DRAIN <br />BACKFLOW PREV DEVICE <br />BATHTUB <br />BIDET <br />CATCH BASIN <br />CLOTHES WASHER <br />DENTAL UNIT <br />CUSPIDOR <br />DRINKING FOUNTAIN <br />FLOOR DRAIN <br />OTHER <br /> <br />OTY OTY <br />INTERCEPTOR <br />LAUNDRY TUB <br />RECEPTOR <br />SHOWER <br /> SiNK <br /> TROUGH DRAIN <br /> TUB/SHOWER <br /> URINAL <br /> WATER CLOSET <br /> WATER HEATER <br /> WET BAR <br /> <br /> Total # Fixturesx $10.00 = $ <br />Lawn vacuum breaker / sprinkler system -- x $4.50 = $ <br />WATER LINES <br />Residential: First l00 fl., or fraction the~of x$20.00 =$ <br /> Foreaaddnll00ftUptoS00 feet -- x$15.00 =$ <br /> First 100 ft. Or fraction thereof x $25.00 = $ <br /> For ea addnl 100 feet x $15.00 = $ <br /> <br />PLUMBING BOARD NO. <br /> <br />CONTRACTORS BOARD <br />REGISTRATION NO. <br />JOURNEYMANS <br />PLUMBERS NO. <br /> <br />CONTRACTOR' S SIGNATURE <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> Property Owner (please print) <br /> <br /> Mailing Address <br /> <br /> City, State, Zip <br /> <br /> Owner's Signature <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 /> Residential: First l00 ft. Or fraction thereof x$30.00 =$ <br /> For ca addn1100 fi. Up to 500 feet -- x $15.00 <br /> Commercial: First 100 ft. Or fraction thereof x $30.00 = $ <br /> For ca addnl 100 feet x $15.00 = $ <br /> <br />STORM DRAINS <br /> Residential: First l00 ft. Or fraction thereof x$30.00 =$ <br /> Foreaaddnll00ft. Up to S00 feet -- x$15.00 =$ <br /> Commercial: For 100 ft, Or fraction the~of x $30.00 = $ <br /> Foreaaddn1100 feet __ x$15,00 =$ , <br /> <br />MINOR INSTALLATION LABELS x $50.00 = $ <br />(Pack of 10 labels ~ $5.00 each, sold only to Plumbing contractors) <br /> <br /> # of Labels N/C <br /> (For New Single Family Dwellings Only) <br /> <br />5. FEES <br /> <br />B. Enter 25% of line A I for Plan Review <br /> (Al + .25), if required <br />C. Investigation Fee (if required) <br />D. Reinspection Fee ($25.00) <br /> <br />Receipt No. <br /> <br />Subtotal <br /> <br />TOTAL AMOUNT DUE <br /> <br />MC 15~45 7/97 <br /> <br /> <br />