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LICENSE ELECTRICAL LOG <br /> MARION COUNTY DEPARTMENT OF PUBLIC WORKS <br /> • BUILDING INSPECTION DIVISION <br /> 5155 SILVERTON RD NE <br /> SALEM,OREGON 97305 <br /> PHONE#(503)588-5147 <br /> FAX#(503)588-7948 <br /> MASTER ELECTRICAL PERMIT <br /> LICENSE LOG <br /> PLANT NAME IArtt. 1 1O 'I7I? L- PHONE#: <br /> PLANT LOCATION: 14O N• l0 rw Ave FAX#: <br /> MAILING ADDRESS: cS61016 <br /> CITY: TMyrad STATE 01 ZIP q 3 <br /> TYPE OF STRUCTURE: <br /> TYPE OF BLDG USE: H DS'pt txt <br /> SUPERVISING ELECTRICIAN: 56-Ap.) ccLL 1Vi") <br /> CONTACT PHONE#: (o ) ?z• j 4'0 6 <br /> DATE NAME LICENSE#/TYPE EXPIRATION DATE <br /> • /zo -. I c I✓AfJ 9ZZjS /o/Z�- <br /> SIGNATURE OWNER/SUPERVISOR: DATE: 0.‘) <br /> I UNDERSTAND THAT THE MASTER PERMIT INSPECTION FEE IS$67.25+12% STATE <br /> SURCHARGE/HOUR PORTAL-TO-PORTAL,(MINIMUM ONE HOUR FOR A TOTAL OF$75.32). <br /> • PAYABLE PRIOR TO THE RELEASE OF THE INSPECTION REPORT.(OAR 918-309-0100.) <br /> Complete this form and return it to BuildingInspection Division. The Electrical Inspector will contact you to schedule a <br /> P P P <br /> date and time for your inspection. <br /> G:Wivlaster Permits\License Electrical Log.doc 4/18 <br />