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FOR CITY VALIDATION <br />Received By:. <br /> <br />Date: <br /> <br />ELECTRICAL PERMIT APPLICATION <br />Please complete all Sections, 1 through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br />TAX ACCOUNT NO. <br /> <br />BUILDING 131SPECTION DIVISION PERMIT NO: <br /> <br /> '700 <br /> <br /> i -II-I lz_l l-lZ-I I I' 1 <br />DIRECTIONS <br /> <br /> 3150 Lanc. nster Dr. NE - Suite C <br /> Salem, Oregon 97305-1398 ~.~,~.., Date:. <br />24 HR inspecfion Line 373-4427 ~~'~J~/~'~by: <br />Office: phone $88~$147 8:00am - 4:30pta <br />,.x.?,. <br /> <br /> 4. FEE SCHEDULE (Complete and ~nt~ Iotalin A1 b~low) <br /> <br /> Items Cml (~c.h) Sum l <br /> $85,00 4 <br /> <br /> $15.00 <br /> <br />PERMITS ARE NON.TRANSFERABLE AND EXPIRE IF WORK IS NOT <br />STARTED WITH1N 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPE2~DED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />ElectficM Contractor Judson's INc. <br />Mail~Ad~'~ P.O. Box 12669 CirySalem <br /> <br />Phor~ 5, 0 3 ~ 3 6 3 4 1 4 1 <br />FAX 5 0 3 ~ 3 9 9 --8 7 6 0 <br /> <br />Contl'~c.~rs Licen~ No. 2 4 --' 1 8 C <br />Contractor Board Reg No. 3 4 6 0 4 <br />sn~Li~ 1 3 6 9 S <br /> <br />2B. FOR OWNER INSTAg J,&TIONS <br /> <br />Mailing Addr--,~s <br /> <br />c~, sta~, ap <br /> <br />Owner's Signature <br /> <br />3. PLAN REVIEW SECTION <br /> <br /> Marion County do~s 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 />(As mqalred by Building Officials) __ <br /> <br />FEES <br />Al. Ente~ total of fees from Sec. g4 <br />A2, Add 5% surchnrge (.05 x A l) <br /> <br />B. Enter 25% of line Al for Plan Review <br /> (Sec. 3), if required <br />C. In~sdSatlon Fee (if requlr~d) <br />D. Re~oecdon F~ ($25.00) <br /> <br />Receipt No. __ <br /> <br />Subtot~ <br /> <br />$ <br /> <br />MC 15-34 7/97 <br /> <br /> <br />