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FO R'CITY VALIDAT! ON <br />Date: <br /> <br />ELECTRICAL PERMIT APPLICATION pR' 20; <br /> <br />MARION COUNTY BUILDING zNSPECTION <br />COMMUNITY DEVELOPMENT CENTER <br /> 285 Church St NE · Room 132 PERMIT NO: <br /> Salem, OR 97301 <br /> <br /> · Date: <br /> 24 ttrl[~l~.' 58~_/7904 <br /> · : ' ' Issued ~y: <br /> <br />If=lease complete all Sections, I through 5 <br /> I. LOCATION OF INSTALLATION BUILDI#G <br /> <br /> P~RIvffrs ARE NON-TRANSFERABLE AND EXPIRE IF WORK IS NOT <br /> b'TAR'ITc~ ~TrltIN 1 ~0 DAYS OF ISSUAN CE OR IF <br /> WORK IS SUSPENDF~D FOR 180 DAYS. ~: <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Properly Owner ~-~"'~I~.A~ [ Phone <br />Coatractor's License No. <br /> <br />Supervisor's License No. &q "~ <br /> <br />2B. FOR OWNBR INSTALLATIONS <br /> <br />Property Owner (please print) <br />Mailing Address { Phrase <br />Ciiy/$tal¢/Zip <br />Owner'8 SJgnalure: <br /> <br />3. PLANREVIEW 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 />~EE SCHE, DUL~ (Completo ~d ~ to~l ~ Al below) <br /> <br /> P~ <br /> Unit <br /> <br />~mlted ~er~ $~.~ 1 <br />~ Msuufa~tu~ H~ or M~ui~ <br /> <br />B. ~v{~s ~ F~s (~n ~t ~cl~e b~ch vi~ui~ see se~n D) <br /> <br />Re~nnect only ~.~ <br />C. Temp~aty <br />2~ ~ps or I~ $35.~ 2 <br /> <br />D. Brau~ Cir~its <br /> <br /> pu~hase ofse~ice of fe~er <br /> ~ branch ci~u[t $ <br /> <br /> b) ~e fee f~ <br /> ~eh additional b~eh ekeuit $ 2.~ . <br /> <br /> ~eh p~p or i~gat[on elsie ~.~ 2 <br /> <br /> Signal ei~uit(s) or a limiled <br /> panel, alieration or exle~i~ ~.~ 2 <br /> <br />Over the nllowablm in any of~e <br />above, ~r ~p~tlon $35.~ <br />O. Min~ ln~a~t~Labe~ <br />Pnck of 10 labe~ ~ $5.~ ~ch $~.~ <br /> <br />H, Oth~ <br /> <br />A2. Add 5% surcharge (.05 x A 1) <br /> <br />B. Enter 25% of liue At for Plan Ravicw <br /> (Sec, 3), ifr~quir~d -- ,a,' ' S- <br />D. Rei~peclion Fee ($25.~) $.__ <br /> <br />MC 15-$4 12/94 <br /> <br /> <br />