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FOR CITY USE ONlY ~ Zoning By: '~-~/~ty: ~-~-~ ELECTRICAL PERMIT APPLICATION Please complete all Sections, 1 through $ 1. LOCATION OF INSTALLATION 3150 Lancaster Dr. ~ - Suite C Sflem, O~gon 97305 JUN 0 ~:3~m ~ ~ Ins~fion Line 373-~27 F~ 588-7948 M~10N C0~ ~HEDULE (c--pier. a~ .~r ,~ in Al, 8BI~ING INSI ....... Nm~ of Insulins ~r ~mt allowed A. ~Me~al Per U~t ~ce Indad~: parcel ID: Site A ddie ss: ,~//7~'~/~'~'-- ~p: P~el Owner: PERMITS ARE NoN'TRANSFERABLE AND EXPIRE IF WORK I ts Nor StARrED WITHIN 180 DAYS OF ISSUANCE OR IF WORK tS SUSPENDED FOR 180 DAY& 2A. CONTRACTOR INFORMATION City:~~ S~:'~ ~p: F~: C~ff~to~ B~ No.: ~ ~ ~ ~ ContractorLicenseNo.: ~- ~J~-- ~ S.~vi~orUce.. No.: / '~ 3 Signature of Supervising Electrician: 2B. FOR OWNER INSTALLATION Property Owner: (,please print) Mailing Address: City: State: Zip: I am the PROPERTY OWNER and own, reside ir~ or will reside in the completed structure and will be my own general contractor. I understand that I must register as a construction contractor Oe the structure is sold or offered for sale before or upon completiot~ If I hire subcontractors, I will him 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 notify Marion County of the name of the contractor Owner's Signature: 3. PLAN REVIEW SECTION Marion 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 p als and spec ficat OhS w th th s application. Items Cost (each) gum 10o0sq~korless -- x $110.00=$ 4 Each additional 500 sq. ft. or portion thereof -- x $20.0O = $ -- Limited Eneegy -- x $30.00 = $ -- 1 Each Manufactured Home or Modular Dwelling Service or Feeder -- x $52.00 = $ -- 2 20o ~mp, of,~ -/ x *~$.0o = $ g~a? Oae/3~panalyDwdl~F~Sq.F~t __ x $ .09=$__ 5. FEES Al. Enter total of fees from Sec. #4 A2. Add State Surcharge (.05% x Al) SUBTOTAL B. Enter 30% of tine A 1 for Plan Review C. Investigation Fee (if required) D. Reinspecfian Fee ($50.00) E. Additional Plan Review ($62.50fnr, minimum one-half hour) E Inspection for which no fee is specifically indicated, ($62.50/hr, minimum one hour) G. Inspection Outside Normal Business Hours, ($62,50/hr, minimum two hours) H. Industrial Plant ($62.50/hr) TOTAL AMOUNT DUE $__ $__ $ $__ MC 15-34 Rev 9/98