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I Date: - ' Salem, Oregon 97301 <br /> <br /> Phone 558-5147 g:00 am - 4:30pm <br />~, t~ ~)A~ //~ Code-A-Phone; 588-7904FAX: 558-7945 SITE #: Permit No. <br /> <br />I, LOCATION OF INSTALLATION <br /> <br />Job Address <br /> <br />PERMYPS ARE NON-TRANSFERABLB AND NON-REFUNDAB LE AND <br />EXPIRE 1~' WORK IS NOT STARTED WlTHI~ 180 DAYS OF ISSUANCE <br />OR IF WORK IS SUSPENDED FOR 1 S0 DAYS. <br /> <br />2A, CONTRACTOR IN~I'ALLATION ONLY <br /> <br />MafllngAddl~ss ~.x"h '~ ' / 7~" ~7~ t:2r~~'~' <br />Property Owner . ~ ] Phon* <br /> <br />C~tracm~s Board Res, No. ~ ~ ] ~ob No. <br />Signature of Su~s~g ~t~an ~~ ~ ~ <br /> <br />Property Owner <br />Mailing Address Phone <br />City/State/Zip <br /> <br />fhe ms aBatmn z~ I~cing made on property I Own wh ch is not lmended for sale, <br /> <br />Owner's Signature ....... <br /> <br />3. PLAN REVIEW SECTION <br /> <br />We will provide plan review ~rvice if you complete Section <br />5B and submit two (2) sets of plans and specifications with <br />this application. <br /> <br />This optional plan review program does not suspend the <br />required submission of lighting power calculations, plans, <br />and specifications when required by the Oregon Structural <br />Specialty Code, Chapter 53. <br /> <br />MC 15-34 11/91 <br /> <br />4. PEE SCHEDULE (Complete and enter total in A 1 below) <br /> <br />A. Residential Per Unit <br /> Service Included: <br /> <br />1000 sq. ft. or less <br />Each additional 500 sq, ft. <br /> or portion thereof <br /> <br />$86,00 -- 4 <br />$15.00 <br /> <br />Limited Enu~g $20,00 ......... <br />Bach ManuFd [4omc or Moduhr <br />Dwelling Scrvi~ or Feeder $40.00 <br /> <br />B, Servtce,s or Feeders (Does not inlcude branch ci rcuits, sec section D) <br /> Installation, Alterations or Relocation <br /> <br /> 201 am~ to 400 mnps <br /> 401 amp~ m 600 amps <br /> 601 amps to 1000 amps <br /> Over 1000 romps or volts <br /> Re~.mncct only <br /> <br />C. Temporary Services/Feeders <br /> Installation, Alteration, or Relocation <br /> 200 amps or less <br /> 201 ~-nps to 400 amps <br /> 401 amps to 600 amps <br /> OVer 600 amps or 1000 volts <br /> <br />D, Branch Circuits <br /> New, Alteration, or Extension Per Panel <br /> <br /> a) Thc fee for branch elicits w/th <br /> purchase of sarv/,¢~ ~, fe~er fee <br /> <br /> Each branch circuit <br /> <br /> b) The fee for branch circuts without <br /> <br /> Each sign or outline lighting __ <br /> <br /> Pack of I0 labels @ $5.00 each <br /> <br /> (As reqtdred by Building Offic~l) <br /> <br /> 50.00 __2 <br /> 60.00 <br />$100.00 __2 <br />$130,00 --2 <br />$300,00 __ 8 <br />$40,00 __ 2 <br /> <br />$35,00 ...... 2 <br />$40.00 <br />$80.00 <br /> <br />$2,00 <br /> <br /> $2.oo ~- <br />$40.00 <br />$40.00 <br /> <br />$40.00 2 <br /> <br />$35,00 <br /> <br />$50,00 <br /> <br />5. FEES <br /> Al, Enter total of fees f~om Sca. #4 · <br /> A2- Add 5% surehal~ge (,05 x Al) <br /> <br /> Subtotal <br /> <br /> B. Enter 25% of line A 1 for Plan Review <br /> (Sec. 3), if rcqui~l <br /> C, lnvc~tigatlon Fee (if required) <br /> D. Reinspectinn Fe~ ($2.5.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br /> Receipt No, , ..... <br /> <br />$ <br />$ <br />$ <br /> <br />$ <br /> <br /> <br />