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FOR~'R-~TY BUILDING INSPECTION DIVISION PE O: <br /> VALIDATION 31so ~c~ter m.~- s,~te c <br />IReceived By: Salem, Oregon 97305-1398 <br /> <br /> ELECTRICAL PERMIT APPLICATION ......... <br /> Please complete all Secttons, I through 5 <br /> <br />1. LOCATION OF INSTALLATION <br /> <br /> ~o~oD~SS 1q3 2 ~ ',._~,,~,,~k ~)~, N~ <br /> ~o~o~ ~l~moo~ L P <br /> ~~ ~/~o I I I I I <br /> <br /> CROSS S~ET/ <br /> D~OHS <br /> <br />~'.03~D~C~O~ A/,-,.-,'. ~'~,~,~ <br /> ,/ <br /> PI~M1TS ARE NON-TRANSFERABLE ~ EXPIRE IF WORK IS NOT <br /> STARTED WITHIN 180 DAYS OF ISSUANCE OR IF <br /> WORK IS SUSPENDED FOR 180 DAYS. <br /> <br />2A. CONTRACTOR INSTALLATION ONLY <br /> <br />~l~c~cal Co.tractor <br />Mailing Address [5~. <br /> <br />P~o,, ..fro <br />~ <br /> <br />co,~-~o~ Li~.~ ~o. <br />C°"tract°r B°ard RcS N°' <br />Supervisor License <br /> <br />2B. FOR OWNER INSTALLATIONS <br /> <br /> Property Owner (please print) <br /> <br /> MaJling 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 15-34 707 <br /> <br />5. FEES <br /> A i. Enter total of fees flora Sec. ~4 <br /> A2. Add 5% surcharge (.05 x Al) <br /> <br />B, Eater 25% of line Al for Plan Review <br /> (Sec. 3), if required <br />C. Inveuiga6on Fee (if requffed) <br />D. Reinspection Fee ($25.00) <br /> <br />R~ceipt No. <br /> <br />TOTAL AMOIffNT DUE <br /> <br /> <br />