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voff6mcE ONLY <br />]Received by: ,, <br />Date: - <br /> <br />MARION COUNTY ~BUILDING INSPECTION <br /> 220 High Street NE <br /> Salem, Oregon 97301 <br /> <br /> Phone 588-~1,47 8:00 ara - 4:30pm <br /> Cod~.A-I~one: 588-7904 <br /> FA.X: 588-794S <br /> <br />iELECTRICAL PERMIT APPLICATION <br />P/ease complete all Sections, i through 5 <br /> <br />SITE #: <br /> <br />Date; <br /> <br />Issued by: <br /> <br />Permit No. <br /> <br />I. LOCATION OF INS~I'AI, I~ATION <br /> <br />Job Address <br /> <br />pERMITS ARE NON.TAANSPERABLE AND NON-REFUNDABTM AND <br />EXt~IRE IF WORK IS NOT STARTED W1TIIIN 180 DAYS OF ISSUANCE <br />OR 11: WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />gA. CONTRACTOR INSTALLATION ONLY <br /> <br />Mailing Address <br /> <br />property Owner I.~, / <br /> ,,.jot" L~ [ ~'ern/ <br />Contraetof~ License No, <br /> <br />COntractor's Board Reg. No. <br /> <br />No, <br /> <br />City/Slate/Zip <br /> <br />The inst allat[oll is being made oa pcrrOe~y I own wbi~ i~ na intended for ~ale, <br /> <br />Owner's Signature ..... <br /> <br />3. PL/~N 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 required by the Oregon Stmcfttral <br />Specialty Code, Chapter 53. <br /> <br />MC 15-34 11/91 <br /> <br />4. FEE SCIqEDULE (Complete and enter total in A 1 below) <br /> <br /> Number of Inspections per p~rmlt allowed <br /> <br />A. <br /> Per <br /> Unit <br /> Ser~'to~ Included: Itc-ms Cost (each) Sum/ <br /> <br />10(10s .fi. of less $85.00 __ 4 <br />EacE sa~di6ona1500 r,q. ft. <br />or pordeo thereof $15.00 <br />L~ ~e~y ~ $~,00 ~1 <br /> moo <br /> <br /> 601 aml~ to 1O00 aml~ <br /> <br /> Reo~nnect <br /> <br />C. Temporary Servl~eeders <br /> <br /> 200 amps or les~ <br /> 201 tanp$ to 400 aml~ <br /> <br /> a) The fee for branch cimui~,~ <br /> purchase of ~e~v~ee or fecclgr.i~e' <br /> ~ach b~a~leh circuit <br /> <br /> h) The fe~ for branch clrcuts without <br /> <br /> Signal cimuit0) at a limited energy <br /> <br />F, ~ch additinnal Insp~tl~ <br />~er ~e a]owable <br /> <br /> Pack g 10 la~Is <br /> <br />H. Other <br /> (As mqMr~d by <br /> <br /> 50.00 <br /> ~60.00 -- 2 <br /> __2 <br />$10000 . 2 <br />$130,00 ~ 2 <br />$300.00 -- 2 <br />$40.00 2 <br /> <br />$35,00 __ 2 <br />$40,00 __ 2 <br />$~o.o0 -- 2 <br /> <br />$2.00 <br /> <br />$3500 <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 /> Al, Enter total of fees from :Sec. #4 <br /> A2. Add 5% mrcharge (,0~ x Al) <br /> <br /> Stlbtotal <br /> <br /> B, Enter 25% of line A 1 for Plan Review <br /> (Sm. 3), if requJxed <br /> C. YmvestlgaticraFee (ff required) <br /> D. Relnspexaion Fee ($2.5.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br /> -Receipt No, <br /> <br />$ <br /> <br />$ <br /> <br /> <br />