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FOR CFI'y USE ~NLY Received By: Date: Zoning By:. City: Receipt #: Amount: $ 1. LOCATION OF INSTALLATION Cross StreegDirections: ~ Project Description: PER2~41TS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT STARTED WITHIN 180 D/IY$ OF ISSU,4NCE OR IF WORK I$ SUSPENDED FOR 180 DAYS. 2A. CONTRACTOR INFORMATION Contractor: Mailing Address City: State: Zip: Phone: Fax: Plumbers License: Journeym~n Plumbing License: Contractors Board Registration Number: Contrac?r's Signature: 2B. FOR OWNER INSTALLATION 1 am the PROPER~ O~ER a~ I rexide in, or will reside in the ~mpleted st~cm~ and will be my own general contractor. I understand that I m~t register ~ a const~ction contractor ~the st~cture is sold or offered for sale b~o~ or upon co~letion. If l hi~ ~bcontra~ors, l will hire on~ subcontractors registered with the Co~t~ction Contractors Boa~. lf l ch~ge my mind and do hire a general contractor who is ~gist~ed with t~ Const~ction Contracto~ Board, I will immediately not~ Marion Coun~ of the name of the contractor: MARION COUNTY BUILD1NG INSPECTION 3150 Lancaster Dr. NE - Suite C Salem, Oregon 97305 8:00am - 4:30pm 24 HR Inspection Line 373-4427 FAX 588-7948 4. FEE SCHEDULE (complete and enter total in 5-Al below) 3. PLAN REVIEW SECTION Marion County does not require service if you complete Section .' specifications with this applieatil MC 15-45 REV 3 NOTICE EFFECTIVE 7-1-99 STATE SURCHARGE CHANGE FROM 5% TO 7% ( )RESIDENTIAL ( )COMMERCIAL ( ) NEW ( ) ADDITION Fixtures (New / Alteration) Area Drain Backflow Prevention Device Bathtub Bidet Catch Basin Clothes Washer Dental Unit Cuspidor Drinking Fountain Floor Drain Wet Bar Total # Fixtures Reconnect (per fixture) Lawn Vacuum Breaker Other Vacuum Breaker l~vices Water Lines Residential: First 100ff.,or fractionthemof -- For ca addnl 100 fi, up to 500 fi Commemial: First 100 B., or fraction thereof -- For ea addnl 100 feet Sanitary Sewer Lines Residential: First 100 B., or fraction thereof __ For ea addnl 100 ft, up to 500 ft Commercial: First 100 fl., or fraction thereof For ea addnl 100 feet Storm Drains/Rain Drains Residential: First 100 ft., or fraction the~of For ea addn1100 l~, up to 500 fi Commercial: Fffst 1~0 fl., or fraction thereof For ea addnl 100 feet Minor Installation Labels Pack of 10 labels @ $10,00 each, sold only to Plumbing eontracto~ s) Dwelling Permit Labels (For New Single Family Dwellings Only) One/Two Family Dwd~in~ Fee: Square Feet: Other (as required by the Building Official) ( ) GAS ( ) ELECTRIC ( ) ALTERATION ( ) RELOCATION OTY. OTY. __ Interceptor -- Laundry Tub I -- Receptor -- Shower ] __ Sink ,~ ~ Trough Drain -- -- Tub/Shower ] Urinal -- Water Closet ~ -- Water Heater -- Other ~t~ x $15.00=$___4 }' x $7.50 = $ __ -- x $7.50=$__1 -- x $10.00=$ x $25.00=$__2 x $16.00=$__ x $30.00 = $ -- x $20.00=$__ x $35.00 =$ 2 x $16.00=$ -- x $35.00=$__ -- x $20.00=$__ __ x $35.00=$___2 x $16.00 =$___ __ x $35.00=$ __ x $20.00=$__ -- x $10.00=$ BASE FEE Assessed om ALL APPLICATIONS: (Exception: Water/Sewer Line Applicafons wino fixtures) Al. Enter total of fees from Section ~4 A2. Add State Surcharge (.05% x A1 + Brae Fee) B. Enter 30% of line A1 for Plan Review C. Investigation Fee (if required) D. Reinspection Fee ($50.00) E. Additional Plan Review ($62.50/hr, minimum one-half hour) $ -- E Inspection for which no fee is specifically indicated, ($62.50/hr, minimum one hour) $ -- G. Inspection Outside Norraal Business Hours, ($62.50/lu', mLnimum two hours) $ $ 25.00