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~" COMMUNITY DEVELOPMENT CENTER <br /> [ 285 Church St NE · Room 132 <br />FORReceivedC1TYby: VALIDATION ~ ~Z/ Salem, OR 97301 <br /> <br />Date: <br /> [ ~,4 hr. [n~lO~ <br /> Oillce: Phone 588~14'7 8:00am - 4:$0pm <br /> FAX: 588-?948 <br /> <br />ELECTRICAL PERIVlff APPLICATION <br /> I <br />Please complete all $ect/on$, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />PERMITS ARE NON-TRANSI~=RABLE AND EXPIRE IF WORK IS NOT <br />STARTE~ WITHIN 180 DA YS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br />Ele~uicalc°"tra~t°rCHERRY CITY I I~'°ne3997609 <br /> ELECTRIC <br />MailingAddmm POB 12668, Salem <br /> <br />C*o~ac~s Lic~r,~ No. 37-620C <br /> <br />Comra~tot°, Board Reg. No. 91668, <br /> <br />2B. FOR O~ INSTALLATIONS <br /> <br />Mailing Addr~s [ Phone <br />City/State/Z¥ <br />Orator's Sign~ure: <br /> <br />3. PLANRBVIEW SECTION <br /> <br /> Marion County does not require a plan review. <br /> We will provide plan review service if you complete <br /> Section 5B and submit two (2) sets of plans and <br /> specifications with this application. <br /> <br />MC 15-$41/96 <br /> <br />MARION COUNTY BUILDING INSPECTION <br /> <br />PERMIT NO: <br /> <br />D~O: <br /> <br />Issued by: <br /> <br />4. FEB SCHEDUL~ (c.~'.pleu, and eat~ total in A1 ~w) <br /> Un~ <br /> <br /> Installation, AR~ation or R~loeati~ <br /> 200 ~ or 1~ ~ 2 <br /> 201 ~m~ ~.~ 2 <br /> <br /> ~1 ~ to 1~ ~ $1~.~ 2 <br /> ~er 1~ ~ps ot vol~ ~ 2 <br /> R~ct only ~ 2 <br /> <br />C. T~sry ~s <br />ln~t~ ~at~ R~t~ <br />~ ~ ~ le~ ~5.~ 2 <br />~1 ~to~ ~ 2 <br /> <br />D. Br~ C~its <br /> <br /> ~ b~n~ c~uit $ ~ <br /> b) ~e fca f~ ~ch ci~ui~ ~ <br /> F~t ~ch c~t i <br /> ~ch addi~n~ b~ch c~t $ 2~ <br /> <br />$~5D0 <br /> <br /> ~q, f~ x $,068 =__ <br /># of Labeb. bvc <br /> <br />5. FEES AL Ente~ to~al of feea f~ Se~. #4 <br /> A2. Add 5% su~harge 605 x Al) <br /> <br />~bte~al <br /> <br />B, Entar 25% of line Al forPlnn Revlew <br /> (Sec. 3), if requlred <br />C. InvenfgaRon F~e (if required) <br />D. Rem~peCtlon Fee ($25.00) <br /> <br /> TOTAL AMOUNT DUE <br /> Receipt No. <br /> <br /> <br />