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IFOR OFFICE USE ONLY <br /> Re'ce;veal by:. <br /> Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />ELECTRICAL PERMIT APPLICATION <br />Please complete all Sections, I through 5 <br /> <br /> 1, LOCATION OP IN.~I'ALLATION <br /> <br /> 220 High Street NE <br /> Salem, Oregon 97301 <br /> <br />Phone 555-5147 8:IXI am - 4:30pm <br />Code-A-Phone: 588-7904 <br /> FAX: 588-7948 <br /> <br />City ~,,~,~ <br /> <br />Directknas <br /> <br />Dcac5ptiot~ <br /> <br />PEILMIT8 ARE NON-TRANSFERABLE AND NON-REFUNDABLE AND <br />EXP[RE IF WORK IS NOT STARTED W1TI I1N 180 DAYS OF ISSUANCE <br />Olq lP WOI?.K IS SUSPENDED FOR 180 DAYS. <br /> <br /> CONTRACTOR INSTALLATION ONLY <br /> <br /> Ownur <br /> Ph~e <br /> <br />Contractor', Uc=sc No. ~'--~t~ ~ <br /> <br />Contfaetor'sBoardI<eg, No, '~,.~ 0~1 [ {'t°bN°' <br />Signatuie of Sul:ervislng l~leetdcJan * . ~ <br /> <br />211, FOR OWNER INSTALLATIONS <br /> <br />Ma~ng Address I Phone <br />C~ty/StatefZip <br /> <br />I'he nstallalio 's be;* g made on property [ own which is not iqtendcd for sa e, <br /> <br />Owner's Signatu~ ....... <br /> <br />3, PLAN REVIEW SECTION <br /> <br />We will provide plan review service if you complete Section <br />5B and submit two (2) sets of plans and specifications with <br />this application. <br /> <br />This optional plan review program does not suspend the <br />required submission of lighting power calculations, plans, <br />and specifications when rcqaired by the Oregon Structural <br />Specialty Code, Chapter 53. <br /> <br />4, FEE SCI:IEDULE (Complete and enter total in/\ 1 below) <br /> <br /> Number ed' Inspections per permit allowed <br /> <br />A. <br /> Residential <br /> Per <br /> Unit <br /> Service Included: Items Cost (each) Sum <br /> <br /> 1000 sq. ft. or less 585.00 4 <br /> Each additional 500 scl. ft. <br /> or pordcm thereof $15,00 __ <br /> LhniteA Energy $20.00 __ 1 <br /> Each Manufd Home or Modular <br /> DwclJJng Senior or Feeder 540.00 __ 2 <br /> <br />B, Services or Feeders (Does not inlcude branch c~ rcults, ~c:c: ~ecl.ion D) <br /> <br />Installation, Alterations or Relocation <br /> 200 amps or less <br /> 201 ;imps to 400 amps <br /> <br />Over ~ff(~ amps or l~l(~00 volts <br /> <br /> 50.00 <br /> ~60.00 <br /> -- 2 <br />$100.00 __ 2 <br />$1~0.00 __2 <br />$300.00 __ 2 <br />$40,00 __ 2 <br /> <br />$35.00 <br />$40.00 <br />$80.00 <br /> <br />$2.00 <br /> <br />$35,00 <br /> $2.00 <br /> <br />$40,00 __2 <br />$40.00 --2 <br /> <br />$40.00 <br /> <br />$35.00 <br /> <br />$50.00 <br /> <br />5. FEES <br /> A 1. ~nter total of fee~ from Sec. #4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br /> Subtotal <br /> <br /> lq. Enter 25% of line A1 for Plan Review <br /> (See, 3), if reqtdred <br /> C. ~vesligalionFee (i/-requlmd) <br /> D, Reinapecdcm Fee ($25,00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />5 35 ~o <br />$ ~ ,:3.% <br /> <br />MC 15-34 11/91 Re?eil>t No, <br /> <br /> <br />