HomeMy WebLinkAboutPermit Electrical 2013-5-21 Electrical Permit Application ,p,SPRINGFIELD.SPRINGFIELD. DEPARTMENT USE ONLY
CITY OF SPRINGFIELD, OREGON Permit no.: S/3 —01 a ( Z
225 Fifth Street•Springfeid,OR 974774P11(541)726-37534FAX(541)726-3689 -�
Date: • .S/Z r / 3
•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() Qty. Cost Total
ea. cost
CATEGORY OF CONSTRUCTION
Residential,per unit,service included: '
❑Residential ❑Government AeCommercial
1,000 sq.ft.or less(4) $134.00 $
JOB SITE INFORMATION AND LOCATION .
•
,// Job site address: X Each additional 500 sq.ft.or portion
V S Z5G. (�w}2 wV . thereof $ 25.00 $
City: Sp nT"e-[.a State: Oa., q
ZIP: 111170 Limited energy(2) $ 32.00 $
Reference: 1-1032 ZZ Co ZSoo Taxlot.: Each manufactured home or modular
/nL, DESCRIPTION'`OF WORK dwelling service or feeder(2) $ 63.00 $
Mot n-60✓1 &yaw-it elis4t �� Services or feeders:installation,alteration,relocation
1��- of' i cw. . Ca r-d 200 amps or less(2) $ 81.00 $
PROPERTY OWNER 201 to 400 amps(2) $ 95.00 $
Name: C krII S c71,W- - -'1- 1 / 401 to 600 amps(2) $158.00 $
• Address: L{ b()r i n Si- N d D. Si-e, (0 0 0 601 to 1,000 amps(2) $205.00 $
City: S?n J 1�`v-(.C� State: OR,. ZIP: q 147 cj 'Over 1,000 amps or volts(2) $469.00 $
Phone: 541-5[1- 8e5e, 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 $
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
479.540(1)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: ES dA- 3;5n 1/412 th t1A-D. a.Fee for branch circuits with purchase of a service or feeder fee:
S
Address: 6997 ,ra TrPe 121 IJ Each branch circuit $ 6.00 S '
City: 4-1A-32n2 State: ore ZIP:971/4o- b.Fee for branch circuits without purchase of a service or feeder fee:
Phone] -4435 S3244 Fax /) -yp;- SE /? Fist branch circuit(2) $ 55.00 $
--� E-mail , J o bars-J{d e_Ca S.,5n& cowl Each additional branch circuit $ 6.00 $
CCB license no.: /63410 BCD license no.:2,05113 as Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: s-fit Si G • Each pump or irrigation circle(2) $ 63.00 $
Print name of signing supervisor: ear'c(- I?OSe-e. Each sign or outline lighting(2) $09[00 $� j,�
Signal circuit or a limited-energy panel,
Signature of signing supervisor: , 4. Q / alteration,or extension(2) $ 63.00 $
• 7• Each additional inspection:(I) $58.00 $
APPLICANT USE
(A) Enter subtotal of abow(pe�fees ll
•
(Minimum Permit Fee S�DUw) $ (09.0V
• (B)Enter 12%surcharge(.12 x[A]) $ f}.2%
`N (C)Technology Fee(5%of[A]) $ 3:4 5
Os% TOTAL fees and surcharges(A through C): $ 80 C13
0/3 60
440-25844(9/08/COM)
SPRINGFIELD -" CITY OF SPRINGFIELD
225 Fifth St
OR f oN TRANSACTION RECEIPT Springfield:OR97477
541-726-3753
• 811-SPR2013-01012
www.springfieldor.gov 3256 GATEWAY ST permitcenter @springfield-or.gov
RECEIPT NO: 2013001005 RECORD NO:811-SPR2013-01012 DATE:05/21/2013
DESCRIPTION, ACCOUNT CODE/TRANS CODE AMOUNTDUE
Balance of Minimum Electrical Permit Fees 224-00000-426102 1004 11.00
Sign or outline lighting 224-00000-426102 1037 17.52
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: 42.12
['=PAYMENT TYPE-, ;�PAYOR 'CASHIER:.DBOWLSBY COMMENTS • !.- ' -,AMOUNT,PAID.
Check E S&A SIGN CORP 42.12
59207
TOTAL PAID: 42.12