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FOR CITY VALIDATION[ <br />Received by: [ <br />Dato: <br /> <br />MARION COUNTY BUILDING INSPECTION <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 />ELECTRICAL PERMIT APPLICATION <br />Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br /> PI~.MITS ARE NON-TRJLNS FERABLE AND EXPIRI~ IF WORK lS NOT <br /> STARTED WlTHR4 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDFA~ FOR 180 DAYS. <br /> <br />2A. COHTRACTOR INSTALLATION ONLY <br /> <br />Electrical Contractor <br /> <br />Phone// Fa~ <br />Properly Owner Phone~ <br />Contractors License No. <br /> <br />Coraractor's Board Peg No. <br /> <br />Signature of Supervising Electrician <br /> <br />Supervisor's Liceme No. <br /> <br />lob No. <br /> <br />2B. FOR OWNIlR INSTALLATIONS <br /> .,--/,:-,--.,¢ '"" <br /> <br />Maili~Ad&~a 1~20, ~,~'- ~9,~ /..~ Phone <br /> <br /> 3. PLANRBVII1W SBCTION <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 /> 4. FEll SCHEDULE (Complete and eater lotol in A 1 below) <br /> <br /> 200 amps or less $35.00 2 <br /> <br />70//. above, per Inspection $35.00 <br /> <br />5. FEES <br />Al. Enter toll of fees fi'om Sec, #4 $.__ <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 Fee (if required) <br /> D. Reinspection Fee ($25.00) $___ <br /> <br /> TOTAL AMOUNT DUE $ <br /> Receipt No. <br /> <br /> <br />