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FOR CITY VALIDATIONI <br />Received By: <br /> <br />Date: <br /> <br /> MARION COUNTY <br />BUILDING INSPECTION DIVISION <br />3150 Lancaster Dr. NE - Suite C <br /> S al~m, Ore$on 97305-1398 <br /> <br /> 24 HR lnsln~lon Line 373-4427 <br /> Office: ph~e 588-~147 8.'~am - 4:30pm <br /> FAX 588-7948 <br /> <br />ELECTRICAL PERMIT APPUCATION <br />Please complete all Sections, I through <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> OS Dm SS [qT D 0v vn$ccoa <br /> <br /> I 1o1 1-1 I-Igl l <br />~OSS S~ET/ <br /> <br /> ST~ ~ 180 DAYS OF ISSU~ OR WO~ IS SUSP~ED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Electrical Contractor <br />Mailing Address City <br /> <br />lAX --~ i <br />Contractors License No. ~ C <br />Contractor Boara P~g No. <br />Supervisor License S <br />Signature of Sapv. Eleeh'ician <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> Propcr~y Owner (please print) ~Ol~"~Dt~ ~'~,O~q~ . <br /> Malli~sA~tc~s~ lq7~'2. Ot. mSa'~-/~O ~, <br /> City, S,te,~p ~__ Or. qTOom <br /> <br /> ~n~'s Sisnamre <br /> <br />$. PLAN ~ $~CTION <br /> <br /> M~on County does not ~qui~ a plan review. <br /> We will provide pl~ ~view ~ice if you complete <br /> Section 5B ~d submit two?) sets of plus ~d <br /> specifications wi~ ~is appdcation. <br /> <br />PERMIT NO: <br /> <br />Date: <br /> <br />Issued by: <br /> <br />4. FEE SCHEDULE (Compl~ ,md enter tota~ in A1 b~low) <br /> <br />5. FEES <br /> <br /> AZ Add 5% surcharge (.05 x Al) <br /> <br />B. Enter 25% of linc A 1 for Hen Review <br /> (S~c. 3), if required <br />C. Investigation Fee (if required) <br />D. R~inspe~ion Fee ($25.00) <br /> <br />Rec~ip~ <br /> <br />TOTAL AMOUNT DUE <br /> <br />$ <br />$ <br />$ <br /> <br />$ <br />$ <br />$ <br />$ <br /> <br />MC 15-34 7/97 <br /> <br /> <br />