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01-08—'21 12:35 FROM— 1-571 PO002/0003 F-791 <br /> 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 jakabign u &WM PHONE#:_grit- x•sztz <br /> PLANT LOCATION: Pot AWL( rd. Wad b(/(4 FAX#: <br /> MAILING ADDRESS: Hai( Peoee 10 #ROM pd gox 4- Ida <br /> CITY: Sid) 1 Q.ILL6 STATE G zip of[3/ <br /> TYPE OF STRUCTURE: Rag . <br /> TYPE OF BLDG USE: &do(' J?a1t <br /> SUPERVISING ELECTRICIAN: Sle.fr 1 gad IV 14 q <br /> CONTACT PHONE#: S153_ r 3111 <br /> DATE NAME LICENSE#!TYPE EXPIRATION DATE <br /> bal <br /> OeaILJS i g�T <br /> Wn 1- <br /> 50-3-pis►-?mz.7 <br /> • <br /> SIGNATURE OWNER/SUPERVISOR: DATE: <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 Building Inspection Division, The Electrical Inspector will contact you to schedule a <br /> • date and time for your inspection. <br /> G:1Mastcr Pennit9\l icenae Electrical Log.doc 4/18 <br />