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FOR CITY VALIDATION Received by: Date: MARION COUNTY BUILDING INSPECTION COMMUNITY DEVELOPMENT CENTER 285 Church St NE · Room 132 Salem, OR 97301 24 hr. Inspection Line 393-4427 Office: Phone 588-5147 8:00am - 4:30pm FAX: 588-7948 ELECTRICAL PERMIT APPLICATION Please complete all SecOons, I through 1. LOCATION OF INSTALLATION ARE NON-TRAH SFF. RABL~ AND EXPIRE 1F WORK lS NO~ STARTED WITHIN 180 DAYS OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAYS. 2A. CONTRACTOR INSTALLATION ONLY Date: Issued by: 4. ~]~1~ SCH]~D~JL]~ (Complete and ~t~' total ~ Al be~w) Unit ~n~ct only ~.~ 2 ~1 ~ to~ ~ ~.~ 2 D. Bran~ Cir~ita n) ~e fee for brach c~ ~ b) ~e fez for brach ci~ ~i~ut ~c~e office ~ f~ fee F~t b~ch c~t ~ch ad~tio~ ~ch c~t $ 2.~ ~ pump or ~gnt~n c~le 2B. FOR OWNI~ INSTALLATIONS Property Owner (p/e~ se prim) Maillng Address ] Phone City/$tntz/'Zip Owner's Signature: 3. PLAN REVIEW SECTION Marion CoUnty does not require a Plan review. We will provide plan review service if you complete Section 5B and submit two (2) sets of plans and specifications with this application. MC 15-341196 Each sign or outlin~ lighting Signal circuit(s) or a limited energy ~el, alt~fion or e~ion P. ~ additio~l l~i~ Over ~e ~able ~ any of ~e ~ve, ~ ~p~t~n G. Min~ In~llation ~b~ ~ck of 10 labels O ~.~ ~ch (~d ~ly to e~cal commot~) H. Oth~ (~ ~m~d by ~il~ ~ciaO ~ling ~it ~bel $40.00 2 $40.00 2 5. FEE. S Al. Enter total of fee~ from Szc. #4 A2. Add 5% surcharge (.05 x Al) $35.00 $5O.OO sq. ft. x $.068 = __ of Labels NIC 5ubtoinl B. Enter 25% of line Al for Plan Review (Sec, 3). if required C. Investigation Fee (if requirzd) D. Reinspection F~e ($25,00) TOTAl. AMOUNT DUE Receipt No.