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L <br /> <br /> ~Pteas%omptete all Sections <br /> <br />I. LO~ATION OF I~STALL~TION <br /> <br />Cross <br /> <br />Zip: <br /> <br /> FOR OWNER I~STALLATION <br /> <br />prop~ty Owne~ 0,/e~e <br /> <br />~t~ tS ~ or offer/or s~e b~ore or upon com~e~. 1/I <br />~ ~t~to~, I will ~ only subeantraetort ~te~d with <br />t~ C~t~ion Co~ B~r~ If I c~nge my mind ~d do <br /> <br />3150 Lanea~ler Dr, NE - Sultc C <br />Salem, Oregon 97305 <br />24 ~ Ins~cfion Line 373~27 F~X 58g-794g <br /> <br /> __ x $110,~;$__4 <br /> <br />FEES <br /> A t. Enter total of fees fpam Sec. ~t4 <br /> .4.2. Add :State Surcharge (,05% x Al) <br /> <br />SUBTOTAL <br /> <br />B, Et~U:r 30% dllne Al f~r Plan Ravlew <br />C. Invcstiga6on Fee 0f r~d) <br />D, ~i~on F~ ($~-~) <br />E. ~dlhon~ Pl~ ~ew ($62.50~, <br /> minimum one-~f ho~) <br />E ~s~fion for w~ch no fee ~ s~cific~y itx~at~ <br /> <br />G. In~on Ou~id~ No~ BusineSs ~o~, <br /> ($62.50a~, ~Mmum ~o ho~) <br /> <br />TOTAL AMOUNT DU~ <br /> <br /> <br />