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IFOR OFFICE USE ONLY <br /> Received by: <br /> Date: <br /> <br />I <br /> <br /> FAX: SSS-79nS SITE #: <br />ELECTRICAL PERMIT APPLICATION I Date: <br />Please complete all Sections, 1 through 5~ Issued <br /> <br />PERMITS ARE NON-TRANSFERABLE AND NON-REFUNDABLE AND <br />EXPIRE IF WORK IS NOT STARTED WITHIN 180 DAYS OF ISSUANCE <br />OR IF WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Electrical Contractor ~ ,~OI J::$ ~ ~ ~t-T IPh°ne <br />Contractors U¢~n$¢ No. o~ 17 - I C~. <br /> <br />$,gnam. nfSupe~i,ing ElecU~cian ~ <br />Supervisor's Uc~.seNo. 3g~S~ {Ph°ne~°2g4 <br /> <br />2B. FOR OWNER INSTALLATIONS <br />Property Owner <br />Mailing Address Phone <br />City/State/Zip <br /> <br />The installation is being made on property I own which is not intended for sale, <br /> <br />Owner's Signature <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 required by the Oregon Structural <br />Specialty Cede, Chapter 53. <br /> <br />MC 15-34 8/94 <br /> <br />4. FEE SCHEDULE (Complete and enter total in A 1 below) <br /> <br /> Number of Inspections per permit allowed .--] <br /> <br />A. <br /> Residential <br /> Per <br /> Unit <br /> / <br /> Service Inclodod: Items Cost (each) Sum/ <br /> 1000 sq. fl. or less $85.00 4 <br /> Each ed&tlona1:500 sq. ft. <br /> or [x~rtlon thereof $15.00 <br /> Limited Energy $20,00 1 <br /> <br />Each Manufd Home or Modular <br />Dwelling Service or Feeder $40.00 -- 2 <br /> <br />B. Services or Feeders (Does not/nlcude branch circuits, see section D) <br /> Installation, Alterations or Relocation <br /> <br /> 201 amps to 400 amps __ $60.00 2 <br /> <br /> ~01 amps m 1000 amps __ $130.00 -- 2 <br /> Over 1000 amps or volts ~ $~00.00 ~ 2 <br /> F'x ,40.00 <br /> <br /> Installation, Altea'aUon, or Relocation <br /> 200 amps or less <br /> 201 amps to 400 amps <br /> 401 amps to 600 amps <br /> Over 600 &raps or 1000 volts <br /> <br />D. Branch Circuits <br /> New, Alteration, or Extension Per Panel <br /> <br /> a) The fee for branch circuits with <br /> ourchase of se~xdce or feedex fee <br /> <br /> Each brlmch circuit / 7_~ <br /> <br /> b) The fee for branch circuts wkhout <br /> m:rchase of service or feeder fee <br /> <br /> ~ branch circuit <br /> Each additionalbranch circu/t <br /> <br />E. Miscellaneous (Service or Feeder Not Included) <br /> Each pump or irrigation circle <br /> Each sign or outline lighting <br /> Signal uircuit(s) or a limited energy <br /> panel, alteration or extension <br /> <br />E Each additional/nspect/o~ <br /> over the allowable in any of the <br /> above, per Inspection <br /> <br />G. Minor Installation Labels <br /> Pack of 10 labels @ $5.00 each <br /> (sold only to electrical contractors) <br /> <br />H. Other <br /> (A~ required by Building Official) <br /> <br />$35.00 2 <br />$40.00 <br />$80.00 --2 <br /> <br />$2.oo z q <br /> <br />$35.00 <br /> $2.00 <br /> <br />$40.00 , 2 <br />$40.00 2 <br /> <br />$40.00 --2 <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% surcharge (.05 x A l) <br /> <br /> Subtotal <br /> <br /> B. Enter 25% of lineAl for Plan Review <br /> (Sec. 3), if required <br /> C. InvestigationFee (if required) <br /> D. R(mspection Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br /> Receipt No. <br /> <br />$ <br /> <br />$ I oq. Zo <br /> <br />$ <br /> <br /> <br />