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~OILC~Y USE ONLY Received By: ,Date: Zoning By: City: Receipt #: Amount: $ ELECTRICAL PERMIT APPLICATION Please complete all Sections, 1 through $ 1. LOCATION OF INSTALLATION Parcel ID: Site Address: ~ t~ 3_.~ ~ CLIJ~) ~ {) PERJflTS ARE NON-TRANSFERABLE AND EXPIRE IF WORK ts NOT STARY~ WITHIN 180 DAYS OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAYS. 2A. CONTI~CTOR INFORMATION Contractor: ~.~t¢~ol,~ 0 [~5 Mailing Add~egs: ci : Contractor I~cense No.: ~"q Signature of Supervising Electrician: 2Bo FOR OWNER INSTALLATION Propeely Owner: (please pdnO Mailing Address: City: State: Zip: I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor. 1 ~nderstand that l must register as a construc~on contractor if the structure is sold or offered for sale befom or upon completion, lf l hire subcontractors, l will hire only subcontractors registered with the Construction Contractors Board If I change my mind and do hire a general contractor who is registered with the Construction Contractors Board I will immediately noti~ Marion County of the Owner's Signature: 3. PLAN REVIEW SECTION IMarion County does not require a plan review. We will provide plan I review service if you complete Section 5B and submit two (2) sets of I plans and specifications with this appliclnion. MARION COUNTY BUILDING INSPECTION 3150 L~ncaster Dr. NE ~ Suite C Salem, Oregon 97305 8:00am - 4:30pm 24 HR Inspection Line 3734427 FAX 588-7948 4. FEE SCHEDULE (comple~ and enter total in Al) Number of Inspections p~r permit allowed -- 1000 sq. fi. or less Each additional 500 sq. ft. or Ixntion diea'eof -- Limltad Energy Each Manufactured Hom~ or Modular Dwelling Service or Feeder Items Cost(e. aek) Sm -- x $110.00~$__4 x $20.00~ $__ -- x $30.00=$ 1 -- x $52.00~$__2 B. Services or Feeders (Does not include branch Circuits, see section D) 200 amp~ or less -- x $65.00 = $ -- 201amps to 400 amps -- x $80.00=$__ Over 1000 amps or volts -- x $390.00 = $ -- 200 amps or less -- x $45.00 ~ $ -- Signal Circuit(s) or a Limited Eneegy F. Each additional Inspection above, Inr Inspection -- x $50.00 = $__ H. Industrial Plant -- x $62.50/hr OnetPa~ Family Dw~aln~ Fee: Sq. Feet -- x $ .09 Dwelflng Permit Labels (For ~iagle Family Dwellings Only) OTHER, as ~talred by the Building Off'lcial TOTAL N/C 5. FEES Al. Enter total of fees from Sec. g~ Ag. Add State Surcharge (.05% x Al) SUBTOTAL B. Enter 30% of line Al for Plan Review C. Investigation Fee (if required) D. Reinspection Fee ($50.00) E. Additional Plan Review ($62.50/hr, minimum one-half hour) $ __ F. Inspection for which no fee is specifically indicated, ($62.50fnr, minimum one hour) $ __ G. Inspection Outside Noml Business Hours, ($62.50/hr, minimum two hours) $ __ H. Industrial Plant ($62.50/h0 $ __ TOTAL AMOUNT DUE $ MC 15-34 Rev 9/98