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ORTC. E USE ONLY <br />Received by; <br />Date; <br /> <br />MARIOI~ COO~NTY BUILDING INSPECTION <br /> .. 220~-I~jh Street NE <br /> Salem, O,,ecjon 97301 <br /> <br /> Phone 588~147 8:00 a,m, - 4:30 p,m, <br /> FAX: 588-7948 <br /> <br /> ELECTRICAL PERMIT APPLICATION <br /> p~e conw~e a/I Sections, l #~rough 5 <br /> <br />1. LOCA'I30N OF INSTAl. LA'noN <br />Job Address cc'O~v- ~'~,-e.~, ~. <br /> <br />SiTE #: Permit No. <br />Data: <br />Issued by:: <br /> <br /> Mailing Address ~ /'~,~ $ Z.~ ~' <br /> Property Owner <br /> <br />Contraotoras Lioense No. ~ ~ ( ~ [ ~ <br />Contra=tufas Board Reg. No, ~ ~ ~ ~ J Job No, <br />~i,~n~ture of Supervising Eiectdc[an~~~ <br /> Supervlsor~s License No,/~ ~ 3 5 I Phone No.~3' ~ <br /> <br />2B. FOR OWNER II~'TALLATIONS <br /> <br />Property Owner <br />'M'sillng Address <br /> <br />I Phone <br /> <br />City/State/Zip <br /> <br />The Installation Is being made on pn~perty I own which Is not Intended for sale, <br /> <br />Owner's Signature <br /> <br />3. PLAN REVIEW SEC310N <br /> Check appropriate item and enter fee in Section 5B~ <br /> <br />__ Connected Load over 200 amps (except single family dwellings) <br /> Building systam over 200 amps (exmpt single family dwellings) <br /> System over 600 volts <br />__ Building over 2 etudes <br /> Building over 10,000 square feet <br /> Occupant load over 30o persons <br /> Manufactured Dwelling Patk/~n Peek <br /> Hazardous Locations <br /> <br />Submit 2 sets of plans with any of the above, <br />Temporary construction services do not apply, <br /> <br />4, FEE .SCHEDULE (Complete and enter total in A1 below) <br />Number of Inspections per permit ellot~el <br /> <br />~. Resldenttel, Single or <br />Multi-Family per dwelling unit <br />($en/ice ir~uded) <br /> 1500 ~q, ft, ut less <br /> <br /> E~h M~,'d H~ or Modul~ <br /> <br />C Tem~m~ ~wlee~F~ers <br /> <br /> ~0 a~ or I~ <br /> <br /> ~M ~ ~s = ~ 0~ vol~ (~ <br /> <br /> One clair <br /> <br />E. MIs~llaneeu~ <br />(S~ ~ F~d~ not ~) <br /> <br /> ~h s~n or outline ligMng <br /> Sign~ cimuit(s) or a li~t~ e~y <br /> <br />F. E~ add'l lee~en <br /> ~er the ~le in a~ ~ <br /> <br />G. ~r Institution ~ls <br /> <br />Items x Cest = Total <br /> <br />2 <br />2 <br />2 <br />2 <br /> <br />2 <br /> <br />2 <br />2 <br />2 <br /> <br />2 <br />2 <br />2 <br /> <br />2 <br />2 <br /> <br />Al, Enter to~ of fees from Se~ <br />A~. Add 5% surchage (,05 x <br /> <br /> Subtotal <br /> <br />B. Enter 25% of line A1 for Plan Review <br /> (Sen. 3), if required <br />C, Inves6ga~en Fee (if required) <br />D, Reinspec~ion Fee ($25,00) <br /> <br /> TOTAL AIVlQUNT DUE <br /> R~,ipt No. <br /> <br /> <br />