HomeMy WebLinkAboutPermit Electrical 2013-10-11 Electrical Permit Application DEPARTMENT USE ONLY
SPRINGFIELD.0 r -
$z h t F t aiiii.1 ei. 41 c Y
CI g O SPRINGFIELD, OREGON; - �
P : S5-00 a ZZ ermit no.
225 Fifth Street•Springfield,OR 97477•PH(541)726-3753•FAX(541)726-3689
Date:
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 t' 1.I tF, ,FEE,SCHEDULE ;'*'"-*s: f,=
Zoning approval verified? ❑ Yes ❑ No Number of ins ections er Item t Cost Total
P P. , O. .' Q Y• ('ea. • - .. cost: :.,
CATEGORY OF :CONSTRUCTION
Residential, per unit,service included:
Residential ❑Government ❑Commercial
>,. r 1,000 sq. ft.or less(4) $134.00 $
t f JOB,:SITEANFORMATION A D t® TION u t ; -
JA�. Each additional 500 sq. ft.or portion
Job site address: 6/ 'I r S I thereof $ 25.00 $
�n
City: S"Fe c State: 00- ZIP: 17977 Limited energy(2) $ 32.00 $
Reference: / /033 JrZ 3 Taxlot.OZ-7Oa Each manufactured home or modular $ 63.00 $
DESCRIPTION OF WORK `'; dwelling service or feeder(2)
v d C.- -- i d 4-` Services or feeders: installation, alteration, relocation
1'� 200 amps or less(2) $ 81.00 $
- - -
PROPERTY OWNER
201 to 400 amps(2) $ 95.00 $
,.
Name: tt j&1_ ,:1-- - -45 L "mot cj� �t�/ / 401 to 600 amps(2) $158.00 $
Address: ge/it 0 Li NOS-Ay / LI /p 601 to 1,000 amps(2) $205.00 $
City: Verv&-r'94 State: !Q- ZIP:97Q-p 7 Over 1,000 amps or volts(2) $469.00 $
Phone: - - 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
479.5400)and 479.5600). 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:Pikitt ; no 'I"\l3p OatI'54jec'r!,e. a. Fee for branch circuits with purchase of a service or feeder fee:
AddressP0)50'09 Each branch circuit $ 6.00 $
City: State:J ZIP: b. Fee for branch circuits without purchase of a service or feeder fee: r
( I\C2 yjvo z
Phone;5 t ,20-(4 Fax:, q j9. --,2pf/'7 First branch circuit(2) / $ 55.00 $ .53
E-mail: Each additional branch circuit 7 $ 6.00 $ utX
CCB license no./69c4,t J BCD license no.:2t2-/9-C. Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: 6..74-$ Each pump or irrigation circle(2) $ 63.00 $
Print name of signing supervisor: 1,�\e1Gtie�' Yoc/'U fr[)- Each sign or outline lighting(2) $ 63.00 $
Signature of signing supervisor: .r/`e ,i it�.Cirl2�i Signal circuit or alimited-energy panel, $ 63.00 $
\ alteration or extension(2)
Each additional inspection:(1) $58.00 $
I: fr ; ?T ' ;APPLICANT>USE
(A) Enter subtotal of above fees
��' / y i r (Minimum Permit Fee$58.00) $ /O 3
1 _jr to • (B)Enter 12%surcharge(.12 x[A]) $ iz 36
1- GD'v (C)Technology Fee(5%of[A]) $ 57 y
TOTAL fees and surcharges(A through C): $ /10 - 4-
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440-2584-1(9/08/COM) Pi- [�'1l ,r•cO1- 0 lI