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FOR CITY VALIDATION <br />Received by:, <br />Date: <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />COMMUNITY DEVELOPMENT CENTER <br />285 Church St NE · Room 132 <br /> Salem, OR 97301 <br /> <br /> 24 hr. Inspection Line 373-4427 <br />Office: Phone 588-5147 8:00am - 4:30pm <br />FAX: 588-7948 <br /> <br />Date: <br /> <br />Issued by: <br /> <br /> ELECTRICAL PERMIT APPLICATION <br /> Please complete ail ~ections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />lob Address ~.~/x_.. ~ ~ <br /> <br />Job Description: ~E~/ ~e~----f~ ~ <br /> <br /> PERMITS ARE NON-TRANSFERABLE AND nXPIRE IF WORK IS NOT <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK 15 SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONI.Y <br /> <br />Electrical Conu'actor <br /> <br />Address <br /> <br />Phone// Fax~ <br />~roperty Owner Phone# <br />Contractors License No. <br /> <br />Contractor's Board Reg No. <br /> <br />l gob No. <br /> <br />Signature of gu~rvising Electrician <br />'.upervisor's License No. I Pho~ ~ <br /> <br />FOR OWHBR INSTALLATIONS <br /> <br />Property Owner (plea~ print) <br /> <br />Mailing Address ~t7~7 <br /> <br />City/State/Zip ~ <br />Owner's Signature: <br /> <br />4. FI~]~ SCH~DUL]~ (Complete and ente~ total in Al below) <br /> <br /> ~v~ lne~d~: 1~ ~t (each) 5 <br />1~ sq. ft. ~ less $~.~ 4 <br /> <br /> ~ ~ion ~e~f $15.~ <br />~mited E~r~ $20.~ ~1 <br />~¢h Manufactured Home or M~ar <br /> <br /> Rennet only ~ 0q~2q~ ~.~__2 <br /> 2~ ~ps or le~ $35+~ ~ 2 <br /> <br /> b) The fee for branch circuits <br /> <br /> Fimt branch circuit <br /> Each additional branch circuit <br /> <br /> E. Miscellaneous (8erviceor Feeder N~ Included) <br /> Each pump or irrigation circle $40.00 2 <br /> Each sign or outline lighting $40.00 -- 2 <br /> Signal circuit(s) or a limited energy <br /> panel, alteration or extension $~0.00 2 <br /> F. Each additional lnspeotion <br /> Over the allowable in any oftbo <br /> above, per lmpeetion $35.00 -- <br /> G. Minor Installation Labels <br /> Pack of 10 labels @ $5.00 each $50.00 <br /> (sold only to electrical contrectors) <br /> H. Other <br /> (As required by Building Or, ciaO <br /> Aurora Dwelling Electrical Fee --gq. fi. x $.068 <br />..... pwelling Permit Label # of Labels <br /> <br />$35.00 ~-'""'- <br />szoo ~ <br /> <br /> 3. PLANRBVIBW SECTION <br /> <br /> Marion County does not require a plan review. <br /> We will provide plan review service if you complete <br /> Section 5B and submit two (2) sets of plans and <br /> specifications with this application. <br /> <br />MC 15-341/96 <br /> <br />FEES <br />A 1. Enter total of fees from See. g4 $. <br />A2. Add 5% surcharge (.05 x Al) $. <br /> Subtotal $. <br /> <br /> B. Enter 25% of line Al for Plan Review <br /> (Sec. 3), if required $. <br /> C. Investigation Fe~ (if required) $. <br /> D. Reimpection Fee ($25.00) $. <br /> TOTAL AMOUIqT DUE $__.~_.~"~ <br /> Receipt No. <br /> <br /> <br />