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STATE OF OREGON <br />DEPARTMENT OF COMMERCE <br />ELECTRICAL SAFETY SECTION <br />401 LABOR & INDUSTRIES BLDG <br />SALEM, OREGON 97310 <br /> <br />PERMIT # <br />LABEL # <br />DATE <br />ISSUED BY <br />OFFICE <br /> <br /> APPLICATION FOR ELECTRICAL INSTALLATION REPORT 5'~-~ <br /> <br />NAME OR F~RM - PLEASE PRINT MAILING ADDRESS /' TELEPHONE # <br />[] ELECTRICAL CONTRACTOR:: LICENSE NUMBER .~ ~'~ ~ , I AM REGISTERED WITH THE BUILDER'S BOARD <br /> / <br /> ORS 701 0~ ~EG[STRA?ION ~ EX~R. DATE ~ ~ ~ SIGNATURE OF <br /> <br /> POSE TO MAKE AN ELECTRICAL INSTALLATIO~OR MY OWN USE AND THIS PROPERTY IS NOT BEING CONSTRUCTED FOR SALE, <br /> LEASE OR RENT FOR THIS REASON, lAM EXEMPT FROM BUILDER'S ~OARD REGISTRATION UNDER ORS 70~,055, TH~ ACTUAL IN- <br /> STALLATION WILL BE MADE BY ME ~ OR BY WHO IS A MEMBER OF MY FAMILY <br /> RELATIONSHIP OWNER'S SIGNATURE <br /> <br /> ADDRES~ ~ CITY' COUNTY <br /> <br />RESIDENTIAL <br /> RESIDENCE WIRING LESS THAN 1000 SQ FT <br /> RESIDENCE WIRING LESS THAN 2000 SQ ET <br /> RESIDENCE WIRING OV(~R 2000 SQ FY, <br /> ELECTRIC HEA'r INSTALLA¥1ON IS EXISTING RESIDENCE <br />SERVICES <br /> TEMPORARY SERVICE <br /> SERVICE CHARGE ONLY IN AN EXISTING RESIDENCE <br /> SERVICE NOT OvER 100 AMPERES <br /> 100 AMPERES BUT NOT MORE THAN 200 AMPERES <br /> 200 AMPERES BUT NOT MORE THAN 400 AMPERES <br /> 400 AMPERES BUT NOT MORE THAN 600 AMPERES <br /> SERVICE OVER 600 AMPERES <br /> SERVICE OVER 600 VOLTS <br />FEEDERS-INSTALLATION ALTERATION OR RELOCATION <br /> NOT MORE THAN 100 AMPERES <br /> OVER 100 AMPERES BUT NOT MORE THAN 200 AMPI]RES <br /> OVER 2iX) AMPERES BUT NOT MORE THAN 400 AMPERES <br /> OVER ,JO0 AMPERES <br /> FEEDER OVER 6(30 VOLTS <br />MISCELLANEOUS <br /> MOBILE HOME SERVICE <br /> MOBILE HOME FEEDER <br /> EACH FARM BUILDING OFHER THAN RESIDENCE <br /> EACH IRRIGATION PUMP <br /> EACH ELECTRIC SIGN OR OUTLINE LIGHTING <br /> EACH RESIDENTIAL SWIMMING POOL <br /> ONE NEW CIRCUIT ALTI]RATION OR EXTENSION <br /> TWO OR MORE NEW CIRCUITS, ALTERATIONS OR EXTENSIONS <br /> OTHER NOT LISTED ABOVE <br />BULK LABELS <br /> ELECTRYCAL CONTRACTORS ONLY {SOLD FROM SALEM OFFICE ONLY) <br /> <br />@ $ 31,20 <br />@ $ 52oo <br />@ $ 7280 <br />@ $ 2080 <br /> <br /> 2080 <br /> 2080 <br /> 31,20 ..... <br /> 520O __ <br />7280 ____ <br />J 04,0O <br />13520 <br />312.oo <br /> <br />2080 <br />3120 <br />5200 <br />6240 <br />8320 <br /> <br />@ $ 20,80 <br />@ $ 20,80 <br />@ $ 2o8o <br />@ $ 20,80 <br />@ $ 2080 <br />@ $ 20.80 <br />@ $ 2080 <br />@ $ 31 20 <br /> <br />@ $ 2080 <br /> <br />4% STATUTORY SURCHARGE INCLUDED IN ABOVE FEES SUB TOTAL $ <br /> LESS [,ABEL FEE <br /> BALANCE DUE $ <br /> <br />THIS PERMIT BECOMES NULL AND VOID IF THE WORK AUTHORIZED 8Y THE PERMIT IS NOT COMMENCED WITHIN 180 DAYS FROM DATE OF ISSUANCE <br />OF SUCH PERMIT OR iF THE WORK AUTHORIZED IS SUSPENDED OR ABANDONED AT ANY TIME AFTER WORK IS COMMENCED FOR A PERIOD OF <br />~80 DAYS 10-3-84 <br /> <br /> <br />