HomeMy WebLinkAboutPermit Electrical 2013-10-7r
Electrical Permit Application naamarrrt.D DEPARTMENT USE ONLY •
CITY OF SPRINGFIELD, OREGON ` I Per,,ilna-; �1I ze,l 3 ot45�
225 Fifth Street♦Springfield,OR 97477ePII(541)726-3753♦FAX(541)726-3689 u
Date: /a/7 /
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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 ❑Commercial 4f7� a
•JOB SITE-INFORMATION' AND LOCATION 1,000 sq.B.or less(4) 7 $(t{�
I f Q / (Acid d Each additional 500 sq.ft.or portion {�/ $ 2 S-
lob site address: U ( eXM thereof a-�V L
City: State: ZIP: Limited energy(2) $ 32.00 $
Reference: Taxlot.: Each manufactured home or modular
$ 63.00 $
DESCRIPT ON OF WORK Services service feeders:feeder(2)
Services or feeders:installation,alteration,relocation
20000 a ess-(2) 61.00 $
. PROPERTY OWNER 201 to 400 amps(2) $ 95.00 $
Name: _.,,_,i Oc Ls L c e- 401 to 600 amps(2) $158.00 $
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Address: Pb , 2 6 Zc'S 601 to 1,000 amps(2) $205.00 $
City: f-2 G-r e I State:O, I ZIP:1 7 y7/ Over 1,000 amps or volts(2) $469.00 $
Phone: - - I Fax: - - Reconnect only(2) $ 63.00 $
E-mail: Temporary services or feeders:installation,alteratjpr,relocation
This installation is being made on residential or farm property 200 amps or less(2) / $ 6340T $ 697
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 S),_L Branch circuits:new,alteration,extension per panel
Business name:'ll) IIt%t ptilim)C..---/l�il GLI'dI IG a.Fee for branch circuits with purchase of a service or feeder fee:
Address: ` �� Le (cL fe Each branch circuit $ 6.00 $
City: State:opf/,///Z1 P/9ll 02`a77 b.Fee for branch circuits without purchase of a service or feeder fee:
Phone �pf 03 p (� Q /,' Fanx, cont./470/t _t C7 l/ptt First branch circuit(2) $ 55.00 $ •
E-mail ) W/1p��J YXttT/ ' , Each additional branch circuit $ 6.00 $
CCB license no.:/'j48/31 BCD license no.as-3/7C, Miscellaneous fees:service orfeeder not included
Signing supervisor's license no.: Atli P /oqS ,// Each pump or irrigation circle(2) $ 63.00 $
Print name of signing supervisor:7m ri-;n , /r - 6-ra Each sign or outline lighting(2) $ 63.00 $
Signature of signing su e[vI5o1C Signal circuit or a limited-energy panel, $ 63.00 $
g g g p ...ter n ^ ' \ alteration,or extension(2)
V�' / Each additional inspection:(I) $58.00 $
(A) Enter subtotal of above fees $
(Minimum Permit Fee$58.00)
(B)Enter 12%surcharge(.12 x[Al) $
(C)Technology Fee(5%of[A]) $
TOTAL fees and surcharges(A through C): ‘5:15-`1(
440-2584-1(9/OS/COM)
SPRINGFIELD CITY OF SPRINGFIELD
1 :,�... 225 Fifth St
rr`C+„ TRANSACTION RECEIPT 3pringfeld,OR97477
.OREGON 541-726-3753
811-SPR2013-01458
www.springfietdor goy 4180 Glacier View DR 4182 permitcenter @springfield-or.gov
RECEIPT NO: 2013001856 RECORD NO: 811-SPR2013-01458 DATE:08/23/2013
LESCRIPTION - „ ' ' „ . ACCOUNT CODE/TRANS CODE 'AMOUNT DUE;°J
Each added 500 sq.ft. or portion 224-00000-426102 1004 82.50
Residence wiring 1,000 sq. ft. or less 224-00000-426102 1004 147.50
Services 200 amps or less 224-00000-426102 1004 178.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 57.24
Technology fee(5%of permit total) 100-00000-425605 2099 23.85
Temp services 200 amps or less 224-00000-426102 1003 69.00
.---__ TOTAL DUE: 558.09
I'' PAYMENT TYPE ^ PAYOR°,,cnsRleREuuRSON, ..° . COMMENTS =-,. ., ',,,„1 - "AMOUNT.PAID"„ ,2 ,,j
Check MIKE GANSEN CONSTRUCTION 558.09
023873 COMPANY .
TOTAL PAID: 558.09
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