HomeMy WebLinkAboutPermit Electrical 2013-8-18 Electrical Permit Application ` DEPARTMENTUSE ONLY
(}I(me SPRINGFIELD..r �$: * ...
CI�'I Y�OE-SPRING LD :QRE�G-O A '"" '0 -S7...7 — D(�y�
r,u.;,ii., „ .;f,sit. ,-, a7`' iii r Permit no.:
ty- _
225 Fifth S[reet•Springfield,OR 97477.PH(541)726-3753.FAX(541)726 3689 ,,
Date: y �j'/ 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. . •
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.,L''OCAL,GOVERNMENTiAPPROVAL ;'2`.4r,--".';', ,r ;" , , A, ,. ` -Ibt FEE,SCHEDULE ;'',;;,,,"' , ; ^ , a.}
Zoning approval verified? ❑ Yes ❑No 'Number of nspections'per item O t Qty 4`east _cost
r r;CATEGORY'xOF:.CONSTRUCTION
Residential,per unit,service included:
❑Residential ❑ Government R.Commercial 1,000 sq. ft. or less(4) $147.50 $
-t1013;jSITE.-INFORMATION 'AN[)':LOCATION'; ,
� A) Each additional 500 sq.ft.or portion
Job site address: 5j Y- . ('_W Fe.-VO i 01 L 81 VC thereof - $ 27.50 $
City: SPR j t4 'ICA G State: D ZIP:CI 7(1 77 Limited energy(2) $ 35.00 $
Reference: 7 Z7 H 3 Taxlot 6. SO.S^ Each manufactured home or modular
�_ tt< - -� dwelling service or feeder(2) $ 69.00 $
\ , ;liDESCRIPTION;.,OFF;MORK _, , -:',,t,,11,4-.11,1,
✓�`A is L- e..e....1S '{ --mod- $y f4a.-.. Services or feeders: installation, alteration, relocation
200 amps orless(2) $ 89.00 $
',41e7:;.'-:`,r l. _,—= , ;; _° f �:; 201 to 400 amps(2) $ 104.50 $
� PRO`P,E1 RTYOWNER ; �''„,g
Name: 6 6---k1/1 f 4 T _ 401 to 600 amps(2) 5174.00 $
Address: (3 • ��'5e srte�- Sr. AS 601 to 1,000 amps(2) $225.50 $
City illy d State: 6t ZIP: 7..m5- Over 1,000 amps or volts(2) $516.00 $
Phone: - - 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
479.5400) and 479.560(1). 401 to 600 amps(2) $138.50 $
Signature: Over 600 amps or 1,000 volts,see services or feeders section above
:v,f-ii-4- 1CONTRACTOR''INSTALLATION '`I,,t,.. e,l. Branch circuits:new alteration, extension per panel
Business name: 1 Y l iI C a. Fee for branch circuits with purchase of a service or feeder fee:
Address: 91/ y) _ey„.` co U e.4- Each branch circuit $ 6.50 $
City: /.Ucl hvJZ. ,,JJ State: O� ZIP: 4-7 I”{01 b.Fee for branch circuits without purchase of a service or feeder fee:
y_ ' - - First branch circuit(2) / $ 60.50 6,...- _
Phone:SH�- y ,y v Fax: I O �+'Q
E-mail: �i)( (d (y j 7 Al 6-114-(N y l £O M S 1(L o c i t UN.•(.411tL Each additional branch circuit / $ 6.50 $
CCB license no.: 18 619 1 BCD license no.: Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: 6 6,s Each pump or irrigation circle(2) $ 69.00 $
1 .
Print name of signing supervisor: 2y .L t l-I ut L. Each sign or outline lighting(2) $ 69.00 $
Signature of signing su ervisor VOU t Signal circuit or a limited energy pang ' $ 80.00 $
g g g p ��i 1�' ' 1t alteration or extension(2) �N.
on 14- R
�j�NT1pN: Oeeg0d by the OS a e etolth Each additional inspection: .SN��NQ% .$80.00 $
roles ad P dhose rule 00A• a n
P h AR g52 )A
tOIIOW {0 �` 'x4-:,..�ve',4 ^"r a� � .,. < . .,�•bn,
1 otlticat.0n Gen • 0 twou es of the rules by tn,`(J7�,.En,pr a t9t 1 fe i ti0 t $
00;9"2"00 obtain the te\eosii'3 ,i°iii
in you may Note'. k ° I\h �� �� ,. ��
0090. ceetOregon Ntl �� �J
ca111n9 the .„„2.2.344). �N`�F� 't,� of � (.1z x[A]) $ J�6o
numbeYCepteY .ISA-g00 PG,( );, hr�l0y e(5%of[Al) $ y
)eTbT i fees and surcharges(A through C): $ 4 3 go
440-2584-1(4/01/2013/COM) _
SPRINGFIELD--- CITY OF SPRINGFIELD
225 Fifth St
TRANSACTION RECEIPT Spnngfield,OR 97477
541-726-3753
811-SPR2013-01846
www.springfield-or.gov 529 W CENTENNIAL BLVD permitcenter @spnngfield-or.gov
RECEIPT NO: 2013001799 RECORD NO:811SPR2013-01846 DATE:08/19/2013
1o14-C41(I0 a7: :. `��',? s�t`, rnf.-� ' "31C ACCOUNTo-CODEI BANS CODE' '- 7—,:--AMOUNT DUE'12;5
Balance of Minimum Electrical Permit Fees 224-00000-426102 1004 13.00
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
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: 93.60
.P,AYMENTAYPE. . _PAY ilkWar RIeR"m�ROSOwI sr V-N C .,:.COMMENTS x, ll'iMillin4M9YNT4PA.MCSaMMIN
Check benedettis meat market and deli 93.60
1824
TOTAL PAID: 93.60
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