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FO!~ OFF[CE USE ONLY <br />Received by: <br />Dat~: <br /> <br />Please complete afl Secfiono, I through 5 ] <br /> <br />Phone 588-5147 8:00 am- 4:30pm <br />Code-A-Phoac: 588-7904 <br /> FAX: 5g~-7945 <br /> <br />Salem, Oregon 97301 u <br /> <br /> Permit Ne, <br /> SITE #: <br /> mn~lul~ L, UUN I Y <br /> 'Date: ",' B~I[DIN~ <br /> <br />L L(R2ATION OFINSTALLATION <br /> <br />Job Add.ss <br /> <br />PERMITS ARE NON-TRANSFEPo~BLE AND NON-REFUNDABLE AND <br />EXP/RE IF WORK IS NOT STARTED Wl'J'Ht'lq 180 DAYS OF ISSUANCE <br />OR IF WORK IS SUSPEN'DED FOR 180 DAYS, <br /> <br />2A, CONTRACfOR INSTALLATION ONLY <br /> <br />Electrical Contractor (~' Ph~e ~ ~ ' <br />Marling Add.ss ~ <br /> <br />Contractor's Boa~l Reg,. No, ~_ ~ ~ Job No. <br />Signature of Su~i~g ~ec~dcian ~ ~ <br /> <br />2B. FOR OWNER IN~I'ALLATIONS <br />Pmpe~y Owner <br />Mailing Addms~ Phone <br />C, ity/S[ at e/Zip <br /> <br />installation is being made on property I own which is not i~le~ded for sale, <br /> <br />Owners Signature <br /> <br />3. l LAN REVIEW SECTION <br /> <br />We will provide plan review service if you complete Section <br />5B aaa submit two (2) sets of plans and specifications with <br />tiffs application. <br /> <br />This optional plan review program does not suspend the <br />required submission of lighting power calculations, plans, <br />and spc£ifications when required by the Oregon Structural <br />Specialty Code, Chapter 53. <br /> <br />MC15.34 11191 <br /> <br />Issued by: <br /> <br />4. FEE SCHEDULE (Complete and enter total h~ A 1 below) <br /> <br /> $er~ ieexne Uded: R esidenila/lPer Uni tNumber of lnsp~tlons,,P~ permit allowed <br />A, <br /> It.s Cost (e~h) Sum-- <br /> <br /> 10~ ~ , fi, ~ ~s~ $85.00 __ 4 <br /> Ea~ ~fi~l 5~ sq, fi. <br /> m ~ the~of $15.00 <br /> <br />Each Manufd <br /> Dwe~ng SemJm or Feeder $40.0~ · , ~ <br /> <br />B. Servl~s o~ FeVers (Does not Ml~de bran~ ci<uits, see section D) <br /> lns~llatlon, AIt~atlons or Rel~atlon <br /> 2~ atllps or less / $50.00 / ~' 2 <br /> ~1 amps <br /> <br />C, Temporary Services/Feeders <br /> <br /> 201 amps to 400 amp~ <br /> <br /> Over 600 amps or 1000 volts <br /> <br /> a) The fee for branch circukq.~ <br /> purchase of ae~Ace or feeder fee <br /> <br /> purchase of service or feeder fee <br /> <br /> Each addldonal branch clxcult <br /> <br />E. Miscellaneous (Service or Feeder Not Included) <br /> Each [~Jmp or ir~gadon circle <br /> Each sign or outline 1/ghtfiag <br /> Signal circuit(s) or a limitr, d energy <br /> <br />F. Each additional Inspection <br /> above, per In ~pectlon <br /> <br />G, Minor Installation Labels <br /> pack of 10 labels @ $.5,00 each <br /> (~old only to electrical cut.meters) <br /> <br />H. Other <br /> (As required by Building Offic~a0 <br /> <br />$100,OO __ 2 <br />$130,00 __ 2 <br />$300.00 __ 2 <br />$40.00 -- ~ <br /> <br />35.00 __2 <br />40.00 __2 <br />80.00 __2 <br /> <br />$2.00 <br /> <br />$35.00 <br /> $2.oo <br /> <br />$40,00 <br />$40.00 <br /> <br />$40,00 <br /> <br />$85.00 <br /> <br />$50,00 <br /> <br />Al, Enter K,~al of fees from Se~. #4 <br />A2. Add 5% st~rcharge (,05 x Al) <br /> <br /> Subtotal <br /> <br />B, E~ter 25% of line A1 for Plan Review <br /> (Sec, 3), if required <br />C. lnvestigationFee (il' required) <br />D. Reimpecaon Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />Receipt No, <br /> <br /> <br />