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1. LOCA~ON OF INSTAI..LATION <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br /> Salem Omgon 97301 <br /> <br /> Phone 588-5147 8.~0 a_m. - 4~0 p.m. <br /> FAX: 588-7948 <br /> <br /> · I'ssued by: <br /> <br />I - <br /> <br />ISTAITI''cD WITt~N 1sO D&~t~ 0F 1~SUANC~ OR IF wORj( Is ~l~DIm ~OR 1~ ~ l <br />2A. CONTRACTOR ~ ONLY <br /> <br />ContractOr's License No. <br /> <br />Oontractor, ~ Board Reg. No. ~,~~1 Job No. , <br />51gna~ure of Supervising Elec~ician ~~ <br /> <br /> FOR OWNER I~STALLA'I10NS <br />P~operty Owner <br /> <br />MalJlng Address J Phone <br /> I <br />Clty/StatelZip <br /> <br />The Installation is being made on property J own whioh ia not intended for sale. <br /> <br />Ownor'~ Signature.,, <br /> <br />Permit No. <br /> <br />4. FEE SCHEDULE (Complete and enter total in A1 below) <br />Number of In~peeflOn~ per permit allowee , <br /> <br />R. Residentlal, Slngleor ~m~ x ~t = To~l <br />~l~-FImlly ~ d~lJl~ unit <br />(8~u~ <br /> <br /> E~ a~l~. ~, 0~ $ <br /> <br /> 1~ S ~, ~ 2 <br /> 101~ste~ -- ~ ~. ,,, 2 <br /> <br /> ~1 a~ 1~ ~ $130, .,, 2 <br /> ~ l~0~or ~J~ ~, ~ 2 <br /> <br />~ T~ ~w~F~ <br />I~, A~ ~R~ <br />~0~le~ , $ ~ ~ <br /> <br />~1~~ ., $ ~, ,,,, 2 <br />~r ~ ~s or 10~ ~ (~ <br />D. ~nch ~mu]~ <br /> <br /> One ~t ~ $ ~, ~ 2 <br /> ~o~ndr~l~ ,, $ ~. ~ 2 <br /> E~h~noimul~otp~on ~ $ 15, 2 <br /> <br /> ~hpu~lr~a~n~le $ ~. ~ <br /> E~hs~n~ouffineligh~ng ~ $ ~. ~ 2 <br /> $1gn~ ~mulz(s) or a limi~ <br /> ~1, a~m~ or ex~on ., $ ~..,, 2 <br /> <br /> ~er ~ ~e In any of <br /> · e~e, psrln~on ~ $ ~. <br /> <br /> P~kofl01~$5,~e~h ~ $ ~, <br /> <br />,,, Conne~ed Load over 200 amps (except ~ fa~ly ¢he~s) <br /> Building system over 200 amps (except single family dwellings) <br />~ System over 600 v~te <br />~ Building over 2 stories <br />~ auiidin9 ova' lO,000 square feet <br /> <br />__ Manufactured Dwelling p~ Pak <br />__ Hazard, s Locations <br /> <br />~Submit 2 sets of plans with any of the above. <br />Temporaly con$'eVC~on services do not apply. <br /> <br />^~. Entre totol of fees {~:~n Ser~ It4 <br />A~. AddS% esrcharge (.05xA0 <br /> <br /> Subtotal <br /> <br />B. Enter 25% of line Al tot Plan Review <br /> (Sec. 3), if required <br />C. Invesligallcm Fee (if required) <br />D. Reblspe~on Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />$ <br />$ <br />$ <br /> <br />? <br /> <br /> <br />