HomeMy WebLinkAboutPermit Electrical 2013-5-21 EleCtI1Cal Permit Application .PRI■o.Ie..o DEPARTMENT USE ONLY
CITY OF SPRINGFIELD, OREGON Permit S/3-o I ° o S
• 225 Fifth Street•Sprin�eld,OR 97477•PH(541)726-3753•FAX(541)726-3689 -
• Date: ' 0 lA q
• 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.
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? ' ❑Yes ❑No Number of inspections per item O Qty. Cost Total
CATEGORY OF CONSTRUCTION
Residential,per unit,service included:
❑Residential ❑Government Commercial
1.000 sq.ft.or less(4) $134.00 $
JOB SITE INFORMATION AND LOCATION
/ Each additional 500 sq.ft.or portion
Job site address: y233 1/iceIY) SI- thereof $ 25.00 $
City: Spn ,k' la( State: 0Q ZIP: ' /yZb Limited energy(2) . $ 32.00 $ .
Reference: /70 Z 3 Z 3 2.. Taxlot.: 01 ?00 Each manufactured home or modular
DESCRIPTION OF WORK dwelling service or feeder(2) $ 63.00 $
• Add "w� bar /-r I..,, . exi. / Services or feeders:installation,alteration,relocation
/ (u.vt GJr/ CGOt.er- �7 r/ 'P ,200 amps or less(2) $ 81.00• $
t'C�-F ilv.,2 � - card-
.
PROPERTY OWNER 201 to 400 amps(2) $ 95.00 $
Name: C/'y t- c Sly n�la.c-I-. � 401 to 600 amps(2) $158.00 $
Address: y��0 Wain S+ Bic(5 17 Sje. 660 601 to 1,000 amps(2) $205.00 $
City: S Pnv'9--`e(c. State:� ZIP: q--N73 Over 1,000 amps or volts(2) $469.00 $
Phone[ -51�-O PJ°J� I Fax: - - Reconnect only(2) $ 63.00 $
E-mail: Temporary services or feeders: installation,alteration, relocation
This installation is being made on residential or farm property - 200 amps or less(2) $ 63.00 s
owned'by me or a member of my immediate family.This 201 to 400 amps(2) . $ 87.00 $
property is not intended for sale,exchange,lease,or rent.OAR
479,5400)and 479.560(1). 401 to 600 amps(2) $126.00 $
Signature: Over 600 amps or 1,000 volts,see services or feeders section above
CONTRACTOR INSTALLATION Branch circuits:new, alteration,extension per panel
Business name: ic_sdi S194 .r/j Awn � a.Fee for branch circuits with purchase of a service or feeder fee:
Address: S''5 75 Pref.If 2 Rd( Each branch circuit $ 6.00 $
City: t1 LA_5e 0 2 I State: OR I ZIP: 971-1uZ b.Fee for branch circuits without purchase of a service or feeder fee:
Phoned -q c- Ssw , I Fax.5il -WI s'b/3 First branch circuit(2) $ 55.00 $
E-mail: , J 0 loer-s.}Q ec as i3 t35. cove Each additional branch circuit $ 6.00 $
CCB license no.: 1673'-7 O I BCD license no.:205 LiS Ces Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: 574e 5/6y // . Each pump or irrigation circle(2) $ 63.00 $
Print name of signing supervisor: l tj /?osJor o Each sign or outline lighting(2) $G9 i00 $ (oc4 no
Signature of signing supervisor: i Signal circuit or a limited-energy panel, $ 63.00 $
�1�� ..d 0 alteration,or extension(2)
Each additional inspection:(I) $58.00 $
r� ' e� APPLICANT USE
J V rfke es a S (`, (A) Enter subtotal of abov f es
JS ` °� (Minimum Permit Fee $(vq• oo
(B)Enter 12%surcharge(.12 x[A]) $ S. zr6
(C)Technology Fee(5%of[A]) $ 3,4S
TOTAL fees and surcharges(A through C): $Sv,13
440-2584a(9t08/con)
T36e
SPRINGFIELD CITY OF SPRINGFIELD
k7, �{ t� ',, TRANSACTION RECEIPT 225 FifeldtOR97477 iK '\OREGON 541-726-3753
811-S PR2013-01009
v. .wspringfield-o r.gov 4233 MAIN ST - permitcenter@spnngfield-or.gov
RECEIPT NO: 2013001001 RECORD NO: 811-SPR2013.01009 DATE:05/21/2013
LDESCRIETI_ON ,. , ow, ,__... ACCOUNT_CODE/TRANSCODE „ h AMOUNT_DUE.`,j
Balance of Minimum Electrical Permit Fees 224-00000-426102 1004 11.00_.
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 1.32
Technology fee(5%of permit total) 100-00000-425605 2099 0.55
TOTAL DUE: 12.87
PAYMENT TYPE PAYOR CASHIER:DeowLser COMMENTS : - 7,.i '. AMOUNT PAID! ,
Check E S&A SIGN CORP 12.87
59207
TOTAL PAID: 12.87
SPRINGFIELD CITY OF SPRINGFIELD
225 Fifth St
TRANSACTION RECEIPT Springfield,OR 97477
OREGON 541-726-3753
811-SPR2013-01009
www.springfield-or.gov 4233 MAIN ST permitcenter@spnrigfield-or.gov
RECEIPT NO: 2013001000 RECORD NO:811-SPR2013-01009 DATE:05/21/2013
LPEsditlii-tloi ---------7.-riT .-.--L---7,----- 1---.,.,,..-.:-?-' ; t-co-bErrtiAlibbE --,- -.----7 --.AMOUNT au EL..,.J
Permit Fee Adjustment-Electrical 224-00000-426102 1004 69.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 8.28
Technology fee(5%of permit total) 100-00000-425605 2099 3.45
TOTAL DUE: 80.73
LPAYMENUYPE , ' .PAYOR. .CASHIER:liedwisthy :. it' - COMMENTS i-3- ::•:1::/; . , ,-,IyAMOUNT PAID' '... `.::.-'":°• ':41
Check ES&A SIGN CORP 80.73
59207
TOTAL PAID: 80.73
•