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· -I FOR CITY VALIDATIONI <br />/ ReCeived By: [ <br /> Date: [ <br /> <br /> MARION COUNTY <br />BUILDING INSPECTION DIVISION <br />3150 Lancast~- Dr. NE - Suite C <br /> Salem, Oregon 97305-1395 <br /> <br /> 24 HR Inspection Line 373-4427 <br /> Office: phone 58g-$147 8:0Om. 4:30pm <br /> FAX 588-7948 <br /> <br />ELECTRICAL PERMIT APPLICATION <br />Please complete all Sections, 1 through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> JOB ADDRESS ~Z{ ~ <br /> <br /> .3--OZO <br /> <br /> CROSS S~T/ <br /> <br />PERMITS ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br />STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Mailing Address City <br /> <br />IAX ~ ~ <br />Contractor Board R~g No. <br />Supervisor License S <br />Signature of Supv. Electrician <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> PropertyOwner(pleaseprint) ~)'-'~J/ ~, ~ <br /> <br />3. PLAN ~EW SECTION <br /> M~on CounW does not requke a plan review. ' <br /> We will provide pl~ review se~ice if you complete <br /> Section 5B and submit two (2) sets of plus and <br />] specifications with ~is application. <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />4. FEE SCt]EDULE (Complete alld enter total in Al below) <br /> <br /> A, Re~deatlal Per UnitNumber of Inspections per permit aRowed ~-~ <br /> Ser~ce Included: Items COat (each) Sum <br /> 1000 sq, ft. or less $85.00 4 <br /> <br /> 200 amps or less $50.~0 ~ · ~ ~ <br /> <br />5. FEES <br />Al, Enter to~al of fees fl~m Sec. #4 $ ~ <br /> A2. Add 5% surcharge (.05 x Al) $ _ <br /> <br />B, Enter 25% of line Al for Plan Review <br /> (Sec. 3), if required <br />C, Investigation F~e (if required) <br />D. Reinspecfion Fee ($25.00) <br /> <br />Receipt No. <br /> <br />TOTAL AMOUNT DUE <br /> <br />MC 15-34 7/97 <br /> <br /> <br />