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rog..o d¢ E ONLy <br />ReceivetI by:, <br /> <br /> Please complete all Sections, 1 through <br /> <br /> COUNTY BUILDING iNSPECTION <br /> 220 High Stmet NI~ <br /> ~ Sflem, ~egon 97301 <br /> ~ P~e 588~5147 8:~ ~ - 4:3~ <br />'~,n~ F~: 588-7~8 SITE ~: <br /> Date: <br /> <br />Issued by: <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />PgP, MI'I'$ ARE NON-TRANSPERABLE AND NON.REFUNDABLE AND <br />gXPIR]~ IF WORK IS NOT STARTED W1THIN 180 DAYS OF ISSUANCE <br />OR IF WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Comractor's License <br /> <br />Comractor'sBoardReg, No, ~2.-~ O"~ I lobNo, <br />Supervisor's License No. ¢'-~_ I. 9_ '~ ~ [ Phone No.~2_~,~.~ <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />PtoI~y Owner <br /> <br />Ma/JJtlg Address <br /> <br />City/State/Zip <br /> <br />The ins[allafion is being made on property I own which is n~ intended for sale, <br /> <br />Owner's SJsnao, i f~ ...... <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 o£ 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 required by the Oregon Structural <br />Specialty Code, Chapter 53. <br /> <br />MC15.34 11/91 <br /> <br />4. FEE SCHEDULE (Complete ~ld enter total in A 1 below) <br /> <br /> Number of In$p~tinns p~r permit allowed <br /> <br />A. <br /> Residential <br /> Per <br /> Unit <br /> Service Included: Items Cost (each) Sum/ <br /> 1000 sq, ft, or less $85,00 ~ <br /> Each additional 5{30 sq. ft, <br /> orar~olcdon thereof $15.00 <br /> Limitr~ Eneqly $20.00 <br /> <br /> Dwelling Seavlce or Feeder $40.00 __ <br /> <br /> Installation, Alterations or Relocation <br /> 200 amps or less <br /> 201 anFi to 4~ amps <br /> <br /> ~r 1~ ~ps or voltq <br /> <br />C. T~porar~ <br /> <br /> 2~ ~ps or less <br /> <br /> 401 ~p$ ~O ~0 am <br /> ~ef ~0 ~ps or 10~ volts <br /> <br />D. Branch C[~ui~ <br /> N~, AIt~atlon, or Extension per Panel <br /> <br /> a) ~e f~ for ~ch ~rc~ts with <br /> ~mhaae of se~m ~ fe~er <br /> <br /> ~ch br<~ ~cuit <br /> <br /> b) ~e f~ for brauch ~uta wi~out <br /> ~has~,~f se~ce or feeder <br /> <br /> F~t branch clm~t <br /> Each ~difional bmn~ ~uit <br /> <br />E. MIs~llan~us (Service or Feeder Not lneladed) <br /> Each ~p or i~gafim <br /> <br /> ~¢r ~ aR~able ~ any of 6lc <br /> <br />G. Minor Installation Labels <br /> Pack ~ 10 la~ls ~ ~.00 <br /> <br />H. Other <br /> (As req~red by BuiMing Off leal) <br /> <br /> ~so,00 <br /> 60,00 ... 2 <br />$100,00 <br />$130.00 --2 <br />$800.00 <br /> $40,00 .... 2 <br /> <br />$35,00 ¢5-.°c 2 <br />$40,00 __2 <br />$80.00 ~2 <br /> <br />$2.00 'Z~ .0 6 <br /> <br />$35,00 <br /> $2.0O __ <br /> <br />$40.00 2 <br />$40,00 <br /> <br />$40,00 <br /> <br />$35,00 <br /> <br />$~o,oo <br /> <br /> 5. FEES <br /> Al, ~nter total of fe~e~ from Sec, #4 <br /> A2. Add 5% surcharge (,O5 x A1) <br /> <br /> Subtotal <br /> <br /> B, Enter 25% of lin* A 1 for Plan Review <br /> (Sec. 3), if requited <br /> C, Inv~figatlonFeo (ff required) <br /> D. Rck~spe. ction Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />.... Receilx No, <br /> <br /> <br />