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FOR CI~ USE ONLY RL'eeived fly: Date: Zoning By: City: Receipt #: Amount: $ ELECTRICAL PERMIT APPLICATION Please complete all Sections, 1 through 5 L~OCATION OF INSTALI[~TION Parcel ID: si~nddress: ]s~'~l~ /~'t~v'~.~ ~¢~ /~, City: ~ let s~.e:~e,~ ~4 Zip: Cr°ss Streee~t/Direc?ns: ~d~tJ,~ ~' ~O- PERMITS ARE NON- TRANSFERABLE AND EXPIRE IF WORE IS NOT STARTED WITHIN 180 DAYS OF ISSUANCE OR IF WORK IS SUSPENDED FOR 180 DAYS. 2A. CONTRACTOR II~eORMATION Contcacto~. Mailing Address: City: State: Zip: Con~a~om Board No.: Con0eactor License No.: Supervisor License No.: Signature of Supervising Electrician: 2B~. OR OWNER INSTALLATION MaillngAddress: ttff4t L~'"~ ~.~¢'lt-40~f~ t~/~ City: ~t) t~'Ot"ff~S' State: ~$t~ Zip: I am the PROPERTY OWNER and own, reside in, or will reside in the completed structure and will be my own general contractor l understand that I must register cma construction contractor if the structure is sold or offered for sale before or upon completion. Ill hire subcontractors, I will hire only subcontractors registered with the Conatruction Contractors Board. lfl change my mind and do hire a general contractor who is registered with the Construction Contractors Board, 1 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 ri:view service if you complete Section 5B and submit two (2) sets of plans and specL, qcations w th this app cat on. MC 15-34 Rev 9/98 MARION COUNTY BUILDING INSPECTION 3150 Lancaster Dr. NE - Suite C Salem, Oregon 97305 8:00am - 4:30pm 24 HR Inspection Line 373-4427 FAX 588-7948 4. FEE SCHEDULE (complete and enter total in Al) Number of Inspections per permit allowed A. Residential Per Unit Service Inrluded: 1000 sq. ft. or less Each additional 500 sq. ft. or portioa thereof __ Limited Energy Each Manufactur~l Home or Modular Dwelling Service or F~,der Items Co~t (each) Sum __ 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) One/T~Family~ll~gFee:Sq.F~ -- x $ .09=$__ N/C 5. FEES Al. Enter total of fees from Sec. ~ A2. Add State Surcharge (.05% x Al) SUBTOTAL B. Enter 30% of line A1 for Plan Review C. Investigation Fee (if required) D. Reinspection Fee ($50.00) E. Additional Plan Review ($62.50/hr, 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, ($62.50Atr, minimum two hours) H. Industrial Plant ($62.50/hr) TOTAL AMOUNT DUE $ $