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OFFiCE USE ONL Y <br /> <br />: Date~ <br /> <br /> ELECTRICAL PERMIT APPLICATION <br /> Please complete all S~tions, I through 5 <br /> <br />LOCATION OF INSTALLATION <br /> <br />MARION COUNTY BUILDIN INSPECTION ?:" <br /> 220 High ~reet NE ,v < ~ ',f" <br /> Salem, Oregon 97301 /''' <br /> Phone 588-51478:00 a,m. - 4:30 p.m, <br /> SITE #: ~/, '/, ~ Permit No <br /> FAX; 588-7948 '~ ' ~, ·, 4- · <br /> <br />J°bAddre~s202560i[y Grim Road ]'~'~C' <br /> Aarora roes Stooones~ Ferry Rd <br /> <br />o~fice for directions to site <br /> <br />Description:; 100 amp service <br /> <br /> ~ ~ ~A~ ~LY <br /> <br /> lR E1 ect~ic <br /> <br />~.~. Bo~ 266, ~ubbard 0R 97032 <br /> <br /> PJorth Nard mn ~chnnl Di ~rl Ct .......................... <br /> <br />,24-205C 1 oo~ No,, <br /> ,50~29 <br /> I <br />Signature of Supervising Electflcla, Z~~ ~ '"~ <br /> <br /> ) Phone No. <br /> I 981-3913 .............................. <br /> <br />Supervl3or's Lioen~e No,, <br />3138S <br /> <br />21[ FOR OWNER INSTAl JLA'nONS <br /> <br />Property Owner <br />Mailing Address I Phone <br />C[tylSt~tefTIg <br /> <br />The installation is being made on property I own which is not intended for sale, <br />[ease or rent. <br /> <br />Owner's $1g~lature <br /> <br />4. FEE SCHEDULE (Comptste and enter te~l in A1 below) <br /> <br />Mule-Family per dwelling unit <br />( 8ervlce included) <br /> 1500sq fl orlsss <br /> Each add'l 5O0 sq. ft. or portion <br /> Ea=h Mfg,'d Home or Modular <br /> Dwelling service or feeder <br /> <br />B. ~er~lce/Feeders <br />(10 Bra~h Cir;uit~ <br /> <br /> 100 alnp~ or leSS <br /> 101 amps to 400 arnps <br /> 401 amps to 600 amps <br /> eot ar~ to lOOO an~ps <br /> Over 1000 ar~ er volts <br /> Reconnect Only <br /> <br />C. Temporary 5ervlce~ee~er~ <br /> <br /> 2o0 amps or leSS <br /> 201 amps to 400 amps <br /> <br /> Over 600 steps or 1000 veils (See 4B) <br /> <br />D. Branch Circuits <br /> <br /> Ofle circuit $ 35 <br /> Two to ten ctn=ulls $ 5o, <br /> Ea~hadd'llenetrcuitsorpo~on __ $ 15. <br /> <br />E. Mlscellsneeus <br />( $ervi;e or Feeder not ~cJu dod) <br />Each pump or irflgation ~yole <br />Ea=h sign or outline ligh~ng $ ,36. <br />Signal eln3uit(s) or a limited eneq3y <br />peeol, alteration orextenslon __ $ 36. <br /> <br />F. Each add'l Inspection <br />over the allowable In any of <br />the above, per Inspection __ $ 35. <br /> <br />G. Minor Instatlabon Labels <br />Paekofl01abels@$5.00eech __ $ 50, <br />(Sold only to eleeYical contractors) <br /> <br />I% Other <br /> (As n~uir~d by Building Official) <br /> <br />$85 4 <br />$ 15. <br /> <br />$~ 2 <br />$130 2 <br /> <br /> 2 <br /> <br />__$35,,__ 2 <br />$40, 2 <br />$80. 2 <br /> <br />2 <br />2 <br />2 <br /> <br />3. PLAN REVIEW SE. C31ON <br /> Check appropriate item and entsr fee in Section 5~. <br /> <br />__ Connected load over 200 amps (except single family dwellings) <br />__ Building system over 200 amps (ex;apt single family dwellings) <br />__ ~ysmm over 600veils <br />__ Building over 2 stsdes <br /> Building over 100000 square feet <br /> Occupant load over 300 persons <br />__ Manufactured Dwelling Pan~afion Pa~ <br /> Hazardous locations <br /> <br />Submit 2 sets of plans wil~ any of 1fie above. <br />Temporary ~nsl~U~on services do not apply,, <br /> <br />Al. Enter tote~ of fees from Sec, ~4 <br />A~.. Add5% surcharge (05xA0 <br /> <br /> Subtotal <br /> <br />B. Enter 25% of line At for Plan Review <br /> (Sec,, 3). if required <br />C. InveslJgaliso Fee (if required) <br />D. P.e]nspe~Jon F~e ($2~00) <br /> <br /> TOTAL AMOUNT DUE <br /> Receipt No. ~ <br /> <br />$ 35. O0 <br />$ 17~ <br /> <br />$36.7$ <br /> <br />$36.75 <br /> <br /> <br />