HomeMy WebLinkAboutPermit Electrical 2013-4- Electrical Permit Application
DEPARTMENT USE ONLY
cJTY.OBI+ SPRINGFIELD, OREGON......Si SPRINGF Permit no.: S73 .763
225 Fifth Street•Springtield,OR 97477•PIt(54i)726-3753•FAX(54I)726-3689 OREGON / 3
Date: / 15 //
This permit is issued under OAR 918-309-0000. Permits are nontransferable. Permits expire if work is not started within 180
days of issuance or if work is suspended for 180 days. 11
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? ❑ Yes ❑No Number of inspections per item() Qty. ?as! Toottatl
CATEGORY OF CONSTRUCTION
Residential,per unit,service included:
❑ Residential ❑Government 51Commercial 1,000 sq.ft.or less(4) $147.50 $
JOB- SITE INFORMATION AND LOCATION
LI I r�^u r-\,,,,,, 6 Each additional 500 sq.ft.or portion $ 27.60 $
Job site address. 1 •�- LOS.�y thereof
City ((.O t>✓10k State:6?.., ZIP:91 L 7o Limited energy(2) $ 35.00 $
Refer, ) OZ 3 2-3 Z Taxlot.:Oft Crib Each manufactured home or modular $ 69.00 $
DESCRIPTION OF WORK dwelling service or feeder(2)
�`�A, C_ /1 �( �U ` q�� Services or feeders:installation.alteration.relocation
1-rvv �f. 200 amps or less(2) $ 89.00 $
Uc ut)e. ow 1-1Ar, bct6c,1
d�PROPERTY 6504,914-4/9 OWNEER 201 to 400 amps(2)' $ 104.50 $
Name: - 734 CL s r 1C-- , 401 to 600 amps(2) $174.00 $
Address:' 43 0 t_srsc^^ Lat4 CA— 601 to 1,000 amps(2) $225.60 $
City:frt:04 13 t.4+✓ I State:X(� I ZIP:33 tie Over 1.000 amps or volts(2) 5516.00 $
Phone: - r I Fax: - - Reconnect only(2) $ 69.00 $
E-mail: ,Temporary services or feeders:installation,alteration,relocation
This installation is being made on residential or farm property 200 amps or less(2) $ 69.00 $
owned by me or a member of my immediate family.This .201 to 400 amps(2) $ 96.00 $
. property is not intended for sale,exchange,lease,or rent.OAR
479.540(1)and 479.5600). 401 to 600 amps(2) $138.50 $
Signature: Over 600 amps or 1,000 volts,see services or feeders section above
CONTRACTOR INSTALLATION
I ,� Branch circuits:net,alteration.extension per panel
Business�name:l.. , kik-i\/S Id f. E\cc tf- t tv C a.Fee for branch circuits with purchase of a service or feeder fee:
Address:l` v�(' �7. 3a( 1 Each branch circuit I $ 6.60 $
City: ccec6ot, 1 I State:(* I ZIPS 7362 b.Fee for branch circuits without purchase of a service or feeder fee:
Phone: It ti-14913 I Fax: T - - First branch circuit(2) I $ 60.50 �'IDJ4�i.�
E-mailA)Sq iAle, ,cons ki5i(ffrL�Cdic .0 Ella additional branch circult I $ 6.60 $ Co j�
' CCB license no.:13(t(`I I� I BCD license no.:C-780 Miscellaneous fees:service or feeder not included
Each pump or irrigation circle(2) $ 69.00 $
L
Signing supervisor's license no.: Li Ij
r Each sign or outline lighting(2) $ 69.00 $
Print name of signing supervisor:,,\c Cie. kA�c t
r .s-, Signal circuit or a limited-energy panel, $ 80.00 $
Signature of signing supervisor: - !f� alteration,or extension(2)
1
Each additional inspection:(1) $80.00 $
L '
43 APPLICANT USE
(-(-91-C�- (,Ot3• 1 ) (A) Enter subtotal of above fees °C
(Minimum Permit Fee$80.00) $ $.41 co,
(B)Enter 12%surcharge(.12 x[A]) $ - u/10�-/-�'
(C)Technology Fee(5%of[A]) $ -1 a`-'V
440-2584-J(4/0 I/20 13/COM) e . . - •
pk‘v t .0 ( °mot..-) j ..0.5 0. 3.oO
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SPRINGFIELD
CITY OF SPRINGFIELD
225 Afth St
TRANSACTION RECEIPT Springfield.OR 97477
OREGON 541-726-3753
811-SPR2013-00763
www.springfield-or.gov 4124 MAIN ST permitcenter@springfield-or.gov
RECEIPT NO: 2013000749 RECORD NO: 811-SPR2013-00763 DATE:04/15/2013
DESCRIPTION 7----- -77- . ;-,-7 ' ;,, ADCOUNt obbtiTRANs CODE ., ' . :4A61101. 4TDDELi
Branch circuits without service or feeder- 1st circuit 224-00000-426102 1004 60.50
Branch circuits without service or feeder-each additional 224-00000-426102 1004 6.50
Permit Fee Adjustment-Electrical 224-00000-426102 1004 13.00
Plan Review Adjustment-Electrical 224-00000-426102 1085 20.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 9.60
Technology fee(5%of permit total) 100-00000-425605 2099 4.00
TOTAL DUE: 113.60
[ PAYMENT-TYPE PAYOR CASHIER:CCARPENTER, ---.. -COMMENTS. - , AMOUNT PAID''[- — - 1
Check COUNTRYSIDE ELECTRIC INC 113.60
1862
TOTAL PAID: 113.60
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