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*- ' I BUILD/lNG INSPECTION DIVISION PERMIT NO: <br />FOR CITY VALIDATION ~ , //~150 Lancaster Dr. NE- Suite C -- -- <br /> __ I~[~ t ~ f/ Salem, Oregon 97305-1398 <br /> <br /> ELECTRICAL pERMIt APPLICATRJN I ~'~.~ ~ .......... <br /> ! ~ 4. F~ ~ltJgJ~Ul,~ (Complete and enter total in Al below) <br /> Please complete all Sections, I through 5 [ ~.u ~ ~, ooll Num~°fln~l~eti~pea'P~'mitall°wed-'--3 <br /> <br />L LOCATION OF INSTALLATION ~[~10~l Cfi [l~q. ~. or 1~ $85.oo __ <br /> <br /> , EXPIRE IF WORK IS NOT <br />STARTED WITH1N 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />Contractors License No. ~ ~-~ -- ~/~ C <br /> <br />SupervlsorLtcens¢ .~ q 6 B S <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br />Owner (please prinO <br /> <br />Mailing Address <br /> <br />City, State, Zip <br /> <br /> Owner's Signature <br /> <br />3. PLAN REVIEW 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 15-34 7/97 <br /> <br />Signal eir~i~O) or a limited ~nergy <br /> <br />2 <br />2 <br />2 <br />2 <br />2 <br /> <br />5. FEES <br /> Al. Enter total of fe~* from Sec. #4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br />B. Enter 25% of line Al fo~ Plan l~view <br /> (Sec. 3), if required <br />C. Inv~tig,~d~ F~e (ff require) <br />D. R~inspcctioa Fee ($25,00) <br /> <br />Receipt No. <br /> <br />Subtotal <br /> <br /> <br />