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Receivea ~,~. , ] - 220 High Street NE <br />Date' ,* .,a- [ Salem, Oregon 97301 <br /> Phone 588-5147 I1:00 am - 4:~0pm <br /> <br /> ELECTRICAL PERMIT APPLICATION /" Date: <br /> Issued <br /> by: <br /> <br />Please complete all Sections, I through 5 <br />1, LOCATION OF INSTALLATION ~.~ ........ <br /> <br />pERMITS AI~E NONiTRANSFEtL~BLE AND NON-REFUI~TDABLE AND <br />EXPIRE IF WORK IS NOT STARTED W]rTItIN 180 DAYS OF I~qSUANCE <br />OR IF WORK IS SUSPEIqDED FOR 180 DAYS, <br /> <br />CONTRACTOR INETALLATION ONLY <br /> <br />Signamr~ofSupc~islngEIectficAan ~'~ ~'. ~ <br /> <br />2Bi FOR O~¢NER INSTAL[J~.TION'5 <br /> <br />pn:~rty Owner <br />Mailing Addrcs~ Phone <br />City]~tat~/Zip <br /> <br />The installation is be}~ag made on prop~rt7 ][ own which, is not ~t~nded <br /> <br />PLAN REVIEW SECTION <br /> <br /> We will provide plan review ~erviee if you complete Section <br /> 5B and submR ~wo (2) sets of pl3ns and specifications with <br /> this appl~eatlon. <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 Slruetural <br />Specialty Code, Chapter 53. <br /> <br />MC ]5-34 ]I/91 <br /> <br />PermitNo. <br /> <br />4, FEE SCHEDULE (Comp eta and ent*r total ~ A1 ~ow) <br /> <br />A. <br /> R~Jdt~t/~J <br /> Per <br /> Unit <br /> t <br /> 8e~i~e Induaed: It,s C~t (ea~) ~/ <br /> <br /> LJmitc~ne~ SZO 100 ~ <br /> Dwe~ing Sc~ ~ ~ccdcr $40,00 ....... 2 <br /> <br /> 200 amps or less <br /> 201 amps to 400 ampa <br /> 401 amps to OXI amps <br /> 601 amp~ to 11200 amI~ <br /> Over 1000 araps or valu <br /> <br />Over,,600 ~np~ or 1000 volt~ <br /> <br />a) The fc~ for branch drcuits ~ <br /> Each branch ckcuk <br /> purchase of selv~ce or fe~ler fee <br /> <br /> above, per ln~ecfion <br /> <br /> Pack of 10 J, abels@ $:5.00 vaeh <br /> <br />Other <br /> (As required by Building Offieia0 <br /> <br /> ~I00 -- 2 <br /> ¢ lO0 ~ 2 <br />$100.00 2 <br />$130.00 __ 2 <br />$8O0.0O 2 <br />$40.00 -- 2 <br /> <br />$85,0O 2 <br />$40,00 <br />$80,00 <br /> <br />$2.00 <br /> <br />$35,00 <br /> $2100 <br /> <br />$40.00 <br />$40,00 <br /> <br />$40100 --~ <br /> <br />$35,00 <br /> <br />$50.00 <br /> <br />5. FEES <br /> Al. Enter to,:al of fees from Sec, #4 <br /> Ag, Add 5% surcharge (,05 x At) <br /> <br /> Subtotal <br /> <br /> I~l En~t 25% of lln6 Al for Pla~ Review <br /> (See, 3). if ~qaired <br /> C, investigation ~ee (if r~quired) <br /> D. ReinSl:,gc6on Fee ¢25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> <br />Receipt No. <br /> <br /> <br />