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FOR CITY VALIDATION <br />Received By: I <br />IDate: <br /> <br />BUILDING INSPECTION DIVISION <br />3150 Lancaster Dr. NE - Suite C <br /> Salem, Oregon 97305-1398 <br /> <br /> 24 HR Inspection Line 373-4427 <br />Office: phone 588-5147 8:00am - 4:30pm <br />FAX 588-7948 <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />ELECTRICAL PERMIT APPLICATION <br />Please complete all Sections, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> Jo. ,D SS tOO2_l 'OcO - tl <br /> <br />CITY V 01tLL <br /> <br /> I: 1-1 '1 1 1-1o I I <br />CROSS STREET/ , I <br /> <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR 1F <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />4. FEE SCHEDULE (Complete and enter total in Al beinw) <br /> <br /> $85.00 4 <br /> <br /> Service Included: <br /> <br />Each additional 500 ~q. fL <br /> or po~on thereof $15.00 <br />Limited Energy $20.00 __ 1 <br />Each Manufactured Home or <br />Modular Dwelling Service or Fe~d~ $40,00 __ 2 <br /> <br />$2.00 <br /> <br />FL-st branch circuit $35.00 <br />Each additional branch alrcuk $2.00 <br />E. Miscallaneous (Service or Feeder Not Included) <br />Each pump or irrigation circle $40.00 <br />Each sign or outline lighting ~40.00 <br />Signal circuit(s) or a limited energy <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> Property Owner (please print} <br /> <br /> Mailing Address <br /> <br /> City, State, Zip <br /> <br /> Owner's Signature <br /> <br />3. PLAN REVIEW 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 />G. Minor Installatinn Labals <br />Pack of 10 labels ~$5,00 each $50.00 <br />(sold only to elec~ical conWactor$) <br />H. Other <br />(As required by Builtling Offialals) <br /> <br />5. FEES Al. En~r total of fees from Sec.//4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br />B. Enter 25% of lir~ A1 for plan Review <br /> (Sec. 3), if required <br />C, Investigation Fee 0 f r~luir~) <br />D. Ralnspection Fee ($25.00) <br /> <br />Subtotal <br /> <br />Receipt No. <br /> <br />N/q, <br /> <br />MC 15-34 7/97 <br /> <br /> <br />