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Zoning By: City: <br />! Receipt ~. :z~% <br /> <br />RECEIVED <br /> <br /> ?fY 2 6 1999 <br /> <br />IPLUMBING PERMIT APPLICATION <br /> Please complete all Sections, 1 through <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK I <br /> IS NOT STAR~ED WITHIN 180 DAYS OF ISSUANCE OR IF I <br /> WORK IS SUSPENDED FOR 180 DAYS. ] <br />2A. CONTRACTOR INFORMATION <br /> <br /> Contractor: <br /> <br /> Mailing Address: <br /> <br /> City: State: Zip: <br /> Phone: <br /> Fax: <br /> Plumbers License: <br /> <br /> Contractors Board <br /> Registration Number. <br /> <br /> Contractor's Signature: <br /> <br />2B. FOR OWNER INSTALLATION <br /> <br />City: /~/gStti State: Ot~ Zip: <br /> <br />I am the PROPERTY OWNER and own, reside in, or will reside in <br />tho completed strucp~re and will ho my own general contractor. 1 <br />understand that I must register as a construction contractor if the <br />structure is soM or offered for sale before or upon completiam lf l <br />hire subcontractors, I will hire only subcontractors registered with <br />tho Con~traction Contractors Board. lf l change my mind and do <br />hire a general contractor who is registered with the Construction <br />Contractors Board, I will immediately notify Marion County of the <br />name of the contracwr. <br /> <br />Agent's Signature: <br /> <br />3. PLAN REVIEW SECTION <br /> Marion County does not require a plan review. We will provide pian [ <br /> review service if you complete Section 5B and submit two (2) sets of I <br /> plans and specifications with this application. I <br /> <br />MC 15-45 Rev 9J98 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> 3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305 <br /> Line 373-4427 FAX 588-7948 <br /> <br />( ) GAS ( ) ELECTRIC <br />( ) ALTERATION ( ) RELOCATION <br /> <br /> Total#Fixtures [ x $15.00=$ /.~,~)t7 4 <br />Reconnect (per fixture) ~ x $7.50 = $ -- <br />Lawn Vacuum Breaker /' x $7.50 = $ ~ -~O 1 <br />Other Vacuum Breaker Dcvicc~ __ x $10.00 = $ -- <br /> <br />Residential: l:u'stl00ft.,orfractlonthea~of __ x $25.00=$__2 <br /> For ea eddn1100 ft, up to 500 ft x $16.00--$__ <br />Commercial: Fa-st 100 ft., or fraction thereof __ x $30.00 = $ -- <br /> Foreaaddnll00feet __ x $20.00=$__ <br /> <br />Residential: Firstl00ft.,orffacfionthereof __ x $35,00--$__2 <br /> For ca addel 100 ft, up to 500 fl x $16.00 = $__ <br />Co~al:Ftmtl00fl.,orfracfionthereof __ x $35.00=$__ <br /> For ca addn1100 feet -- x $20.00 = $ -- <br /> <br />Minor Installation Labels __ x $10.00 = $__ <br />Pack of 10 labels @ $10.00 each, <br />sold only to Plumbing contmclors) <br /> <br />OnetI'woFamllyDwellingFe~:SquamFe~: -- x $ .09=$__ <br />Other (as reqaircd by the Building Ofl'~ial) $ o~ .~ 0 <br /> <br />5. FEES <br /> <br />BASE FEE Assessed on ALL APPLICATIONS: <br />(Exception: Water/Sewer Line Applications w/no fixtures) <br /> <br /> Al. Enter total of fees from Section//4 <br /> A2. Add State Surcharge 605% x A1 + Base Fcc) <br /> <br />SUBTOTAL <br /> <br />$ 25.00 <br /> <br />$ <br /> <br />$__ <br />$__ <br />$__ <br />$__ <br /> <br />B. Enter 30% of line A1 for Plan Review <br />C. Investigation Fee (if required) <br />D. Reinspection Fee ($50.00) <br />E. Additional Plan Rcvinw ($62.50gar, <br /> minimum one-half hour) <br />F. Inspection for which no fcc is specifically indicated, <br /> ($62.50gar, minimum otto hour) <br /> <br />O. Inspection Outside Ncnmal Business Hgur, ls, <br /> ($62.50/hr, minimum two hours) ~ f~'--/'J~'~o <br /> TOTAL AMOUNT DUE <br /> <br /> <br />