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FOR OFFICE USE ONLY 'Rc~e~ive'd by:, Date: COUNTY BUILDING INS Salem, Oregon 97301 IJ lli JAN 2 7 1995 Cx~l~.AO~bonc: $$8-7904 FAX: 588.7948 I ELECTRICAL PERMIT APPLICATION ~ Please complete all Sections, I through 5 I 1. I.,OCATION OF INSTALLATION ~?~ .......... ~ ~ WO~ IS NOT ~ ~ 180 DAYS OF ISS~CE OR ~ WO~ IS SUSP~D ~K lg0 DAYS, FOR OWNER INSTALLATIONS MaJ~g Address I Phone City/$1al¢/Zip The installation is t~ing made on prol~ny I own which is n~: J, mgnded for s~,e, lsase, or rcnk Ow~?s Signature 3, PLAN REVIEW SECTION We will provide plan review service if you complete Section 5B and submit two (2) sets of plans and Specifications with this application, This optional plan review program does not suspend the requir~ submission of lighting pOwer calculations, plans, and sI~eificafi~s when r~qui~ by the Oregon Stmet~al Specialty Code, Chaptex 53. MC 15-34 11191 " Permit No, SITE ~ARiON ~0UN i'~ ' oaBU!Lg!NG Issued by:, A, R~ldentla ~r Unit Se~l~ lucluded~ I~s C~t (~&) Sum{ Each M~ugd H~e or M~ar ~e~ 8e~ or F~ $40,00 ~. $er~ or Feeds, ~s n~ ~udC ~anch dtcuits, s~ s~d~ D) ~.00 ~r 1~ ~ps or vol~ $300.~ ~ 2 Temporary Ser~lcea/P~ders Installation> Alteration, Or Rd~atlon 2~ ~ps ~less $35.00 201 ~ps to ~ ~ $40.00 401 ~ps to ~ ~ $80.00 ~er ~ ~ps or 1~ vol~ New, Al~tlon, or ~tmslon ~r Panel ~rchasa of se~ Or fermi fee ~ b~ch c~uit $2.~ b) ~ f~ f~ branch ~uts Fi~t b~nch civet ~ch addi~ branch c~c~it E. Mlseell~nmos (Servl~ or F~eder Not Included) Each ~mp ~ i~ga~ ~ch s~n ~ ~ ~h~g ~n~. ~herafion ~ ext~si~ ~er ~e a~owab~ ~ Pa~ of 10 la~l~ ~ $5.~ ~aeh ~ $50,00 ( ~ reqMr~d by Bu~d~ Offic~l) 5. FEES B~% of ~ C, I~v~au~ b~ (ff mquir~) $ D, ~ (~,~) ' . $ ~TAL AMO~ DU~ Rcc~ip~ No.