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OFRC C NL Y <br />Received by; <br />Date". <br /> <br />MARION C~UNTY BUILDING INSPECTION <br />220 High ~eet NE <br /> Sa~m, Oregon 97301 <br /> <br />Phane 588-5147 g,l)O a,m. - 4:30 p.m. <br />Code-A-Phone: 588-7904 <br /> FAX: 588-7948 <br /> <br /> Ei FCTRlCAL I:)ER~JT .6J~F~-IC, A'iiON <br /> Please co~e all Secflor~s, 1 <br /> <br />city <br /> AUMSVILLE I erode St. PORTER RD. , <br /> <br />Issued by: <br /> <br />FTRST PO~ER POLE SOUTH OF PORTER <br /> <br />~ABT,~ q~/ ~O~T~R SUPPLY MOUSED ON <br />POWER POLE <br /> <br />"Mailing Address <br /> <br />Property Owner <br /> <br />Cont~e.¢t(~r'a L[~ense No_ <br /> <br />Oontrac~Or'a goard Reg. No, <br /> <br />I Job No. <br /> <br />Signature of Supervising Eleetrlslan <br />Superviaor's License No, <br /> <br />2B. FOR OWNE~ I~STALLATIONS <br /> <br />'Phone No. <br /> <br /> Property Owner <br /> COUNTRY CABLEVISION, LTD. <br />MaClang <br /> Abbrsss7522 JORDAN ST. ~ S~ ~hone 588-8247 <br />~I~/State/ZlP SALEM, OR 97301 <br /> <br />The installation is being made on proper ty~)own which Is not intended for sale, <br /> <br /> Owner*s Signature~. , ~P~S~D~NT <br /> <br /> ~ ~am ~ ~ en~r ~ in ~n SB. <br /> Conn~ <br /> <br /> ~s~m ~er ~0 vol~ <br />~ Building ~er 2 <br /> <br />~ ~t ~ ~er <br />~ ~u~ ~lling <br /> <br />Submit 2 sets of plans with any of the above. <br />Temporary co~s/zuo~n se(vices do not apply. <br /> <br />4. FEE SCHEDULE (Oempleta and enter total in A~ below) <br />Number of Inspe(~t]ons per permit <br /> <br />A. ~s~entlal, Sthgle or I~ms x ~st = To~l <br /> <br />Multt-Femtty per d~eelltng unit <br />($e-W=einc, luded) <br /> 1500 sq, ~ or less <br /> <br /> E~h M~.'d HO~ or M~lar <br /> Dwelling ~ ~ f~r <br /> <br />B. ~lc~ere <br /> <br /> 101~s~ <br /> ~l~sto~ <br /> <br /> ~er 1~0 ~ ot ~1~ <br /> R~nn~lOnly <br /> <br />C. Tem~ <br />~,A~=~ or <br /> <br /> ~1~~ <br /> ~l~sto~ <br /> ~ ~ ~s or I0~ ~ (S~ <br /> <br />D. <br />N~, A~ or ~ P~ P~eI <br /> ~e Gt~lt <br /> <br /> E~h ~d'l mn ~ul~ Or po~an <br /> <br />(~ ~ F~r not ~d~) <br /> Ea~ pu~ ~ Ir~aflan ~le <br /> <br /> ~ign~ ~mult(a) or a I1~ enemy <br /> <br />F, E~h ~d'l ths~eflo~ <br /> ~er mo NI~Io In aay of <br /> me ~ove. per In~on <br /> <br />G. Mtaor Ina~llaUon <br /> P~kof 10 ~els ~ $5,~ ~h <br /> ~o~ on~ ~ e~l ~) <br /> <br />H. <br /> <br />At~ Enter lotal of fees from Sec. #4 <br />A~, Add S% su~ha~e <br /> <br /> Subtotal <br /> <br />B. Enter °f~%oflineAt focPlan Review <br /> (Sec. :~), if required <br />C. tnves'.tga~ Fee (ff <br />D, ~Jns~n F~ ~.00) <br /> <br />TOTAL AMOUNT DUE <br /> <br />35. O0 <br />36.75 <br /> <br />$ 36.75 <br /> <br />MC ~ r,~ R~,. r,*~o Rece~t No. <br /> <br /> <br />