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MARION COUNTY <br />[- ' I BUILDING INSPECTION ~MSION <br /> FOR CITYVALIDATIONI 3150 Lancaster Dr. NE- Suite C <br /> · . ~ Salem Oregon 97305~1398 <br /> ecelve(~ <br /> <br /> ate: I 24 HR I~i~9~427 <br /> -- -- -- I Office: phone~l~~ - 4:30pm <br /> <br /> Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> cross Sr~ET/m <br /> <br />I PE~TS A~ NON'T'NSFE'BLE A~ E~I~ IF WORK IS NOT ] <br />STATED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WO~ IS SUSPENDED FOR 180 DAYS, <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Property Owner (pleose prinO <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 />I Section 5B and submit two (2) sets of plans and <br /> specifications with this appiication. <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />o~E SCH~DU~ (Compile and ~nttr total in Al below) <br />_~IAL ~ COMMERCIAL [~ USE: <br />$ ~w El ,~r~noN El ~DmO~ El ~--~anON El <br /> <br /> OAS El <br /> <br />FORCED AIR UP TO 100,000 BTU <br />FORCED AIR OVER 100,000 BTU <br />FLOOR FURNACE <br />DUCTS (ALTERATION/EXTENSION) -- <br /> <br />GAS FURNACE <br />GAS FIREPLACE/INSERT <br />GAS WATER HEATER <br /> <br />ELECTRIC El <br />--~ x s6.oo =$_~ <br /> x $7.00 <br /> <br /> x $6.00 <br /> x $7.50 <br /> <br /> x $7.50 <br /> x $7.50 <br /> <br /> GAS LOGLIGHJ'F~P. _~..,~.~ ~...~ __ x $7.50 <br /> GAS BARBEQUE <br /> <br />GAS PIPING <br /> Eacho~tl~upto4outlets ~ x S2.00 =$ ~ t <br /> <br /> FLOOR MOUNTED x $6.00 = $ <br /> ~AT ~UMP <br /> <br />~ # o f Labels <br />(For New Single Family Dwellinga Only) <br /> <br />5. FEES ~_~ <br /> Al. Enter total of f~s from S~. ~4 $ <br /> A2. Add 5% sumharge (.05 x Al ) <br /> Subtotal $ <br /> B. Enter 25% of line Al for Plan Review <br /> (Al + .25), if required $ <br /> C. Investigation Fee (if mgaired) $ <br /> D, Reinspection Fee ($25.00) $ <br /> TOTAL AMOUNT DUE $ <br /> Receipt <br /> No. <br /> <br />MC 15-41 7/97 <br /> <br /> <br />