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FOR OFFICE USE ONLY <br />Received by: <br />Date:. <br /> <br />ELECTRICAL PERMIT APPLICATION <br />Please complete all Sections, 1 through 5 <br /> <br />' 220 l-Iigh Street NE ~[~ )~3 -- "'~lt} ! <br />Salem, Oregon 97301 aa" ~ <br /> <br /> C~e-A-~on~: 588-7~4 ~... ,~ermit No, <br /> ~AX: 588.7948 SITE ~["~RIONi~ bUu~ ~ ' <br /> Dat~,.- n,~m I~pFCT[0N <br /> Issued by: <br /> <br />1, LOCATION OFINSTALLATION <br /> <br />PERMITS ARE NON-TRANSFERABLE AND NON-REFUNDABLE AND <br />EXFIRE IF WORK IS NOT STARTED WiTH~ 180 DAYS OF ~SUANCE <br />OR IF WORK IS SUSPthNDED FOR 180 DAYS, <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />FOR OWNER iNSTALLATIONS <br /> <br />Mailing Address Phone <br />City/State/Zip <br /> <br />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 applicatioa, <br /> <br /> This optioaal 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 />MC 15-34 I1/91 <br /> <br />4, FEE SCHEDULE (Complete and enter total in A I below) <br /> Number of lnsp~tlens per permit allowed ~] <br /> <br />A, <br /> Residential <br /> Per <br /> Unit <br /> Service IncloSed; Items Cosl (each) Sum <br /> 1000 sq, fi, or less $85.00 ~ 4 <br /> Each ad~fiotml ~00 sq. ~t. <br /> or po~cm ~hereof $1fi,00 <br /> Limited Energy $20.00 1 <br /> <br /> .... $40,00 <br /> <br />Se~wlc-~ or Feeders (Does not iutcxtde braxxeh ~cuit~, ~ sectm~ <br /> <br /> Installation, Alteration, or Relocation <br /> 200 amps or less ~ <br /> 201 ami~ to 400 amps <br /> 401 amp~ to 600 amps <br /> <br /> Ove[600 amps or 1000 vol~ <br /> <br /> b) The f~ fOX blanch ~lX:/lt S witht~at <br /> / <br /> <br />H, Other <br /> (Aa' required by Buildin8 Official) <br /> <br /> ~0.00 <br /> 60.00 <br />$100.00 ......... 2 <br />$130,00 __ 2 <br />$300,00 __ 2 <br /> $40.00 <br /> <br />$35,00 <br />$40.00 <br />$80.00 <br /> <br />$2,00 <br /> <br />$2,00 <br /> <br />$40,00 <br />$40,00 <br /> <br />$40.00 ..... 2 <br /> <br />$3g.00 <br />$50.00 .... <br /> <br />5. FEES <br /> Al. Enter trial of fees from Sec. #4 <br /> A2, Add 5% surcharge (,05 X Al) <br /> <br /> Subtotal <br /> <br /> B. Enter 25% of line Al for Plan Review <br /> (See. 3). if required <br /> C, Investigation Fee (ff required) <br /> D. Rc~aspe~dco Fee ($2S.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />.... Receipt No. <br /> <br /> <br />