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OI~ LII ~.,)[~[I~A l IOI~I 3150 Lancaster Dr. NE - Suite ~ <br />Rffceived By: ~, S~em. Oregon 97305-1398 ~ <br /> <br /> I : p 8:~am- 4:,0pm <br /> F~ 588' 948 2' ~/I/I <br /> ~ -- ~,. ~,. .... o~ Y~/ <br /> <br />1. LOCATION OF INSTALLATION <br /> T^X^CCO~TNO. I~ t0 I~ la 1~ I-I ,~1~ [0 <br /> JOB ^DD~SS l~O 'Fo~ ~J/-fi' <br /> CITY ~ IT' ', ~ <br /> <br /> ~o~ I~F I~ I-I~l~ P I-I~P <br /> CROSS ST~ET/ U~ ~A ~1~< I <br /> DI~C~ONS <br /> <br /> PE~ITS A~ NON-T~NSFE~BLE AND E~I~ IF WO~ IS NOT <br /> STARED WITH~ 180 DAYS OF ISSUANCE OR 1F <br /> WO~ IS SUSPE~ED FOR 180 DAYS. <br /> <br />2A. CONT~CTOR INST~LATION ONLY <br /> <br />Electrical Contractor <br />Mailing Address City <br /> <br />Phone -- <br />FAX -- -- <br />Contractors License No. -- C <br />Contractor Board Reg No. <br />Supervisor License S <br />Signature of Supv. Electrician <br /> <br />2B, FOR OWNER INSTALLATIONS <br />Propcrty Owaer (pZease print) ~ I~ E ~ [3.]- 5~] ~l~'.~,~ b <br />Mailing Address ~ ~ ~// <br /> <br /> Phone flolz I-Icl~lvl-I~P I~1/ <br /> <br /> / <br />3. PLAN ~VIEW SECTION <br /> <br /> M~ion Coun~ ao:s ~ot require a plan renew. <br /> W~ will provi& plaa r~vi~w senic~ if you compl~t~ <br /> Sec~on 5B and submit ~o (2) sets of plus ~d <br /> sp~ci~catioas with tMs application. <br /> <br />1000 sq. ff. or less $85.00 4 <br />Each additional 500 sq. fi~. <br /> or portion thereof $15.00 <br />Limited Energ~ $20.00 1 <br />Each Manu faclured Home or <br />Modular Dwelling Service or Feeder $40.00 2 <br /> <br />B. Se~ices or Feeders (Does not kn¢lude branch circuits, ~ee section D) . <br /> <br />201 amps to 400 amps $60.00 2 <br />401 amps to 600 amps $100.00 2 <br /> <br />(As vequffed by Building Officials) __ <br /> <br />5. FEES <br /> <br />B. Enter 25% of line A1 for Plan Review <br /> (Sec. 3), if required <br />C. Investigation Fee (if required) <br />D. Reinspection Fee ($25.00) <br /> <br />Receipt No. <br /> <br />Subtotal $ .~. ZO <br /> $ <br /> <br />TOTAL AMOUNT DUE <br /> <br />MC 15-34 7/97 <br /> <br /> <br />