HomeMy WebLinkAboutPermit Electrical 2013-10-28 Electrical Permit Application DEPARTMENT USE ONLY
SPRINGFIELD (J 51/0013- `/
�S SPR[NerdetI), OREGON ' td ' Permit no.: b 1I - 021g7
225 Fifth Street[Springfield.OR 97477•P11(541)726-3753•FAX(541)726-3689 :. ‘ OREGON ??
Date: P
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 id Commercial
JOB SITE INFORMATION AND LOCATION OOO sq.R.or less(4) $147.50 S
IJIJ c r' F-I J A 1/, el,
Each additional 500 sq.0.or portion $ 27.50 $
Job site address: V thereof )
r_
City: G State: O,_ ZIP: q 7403 Limited energy(2) $ 35.00 $
Reference: ' 703 3Y 33 Taxlot.:C0700 Each manufactured home or modular $ 69.00 $
DESCRIPTION OF WORK dwelling service or feeder(2)
fan', Seitlice- �?r /- z-e Services or feeders: installation,alteration,relocation
CO T(J DLO LEC 200 amps or less(2) $ 89.00 $
CON tra a4- 201 to 400 amps(2) $ 104.50 $
PROPERTY OWNER
Name: Patti 1 ntSl1 4 kQ ry)#-C 401 to 600 amps(2) $174.00 $
Address:: I'S1 'fy5t ni 1 .1 SW/ 601 to 1,000 amps(2) $225.50 $
City: eUrn/) . State: 04 I ZIP: q '?4 cc Over 1,000 amps or volts(2) $516.00 $
Reconnect only(2) $ 69.00 $
Phone: Fax: - -
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 $49,60
owned by me or a member of niy immediate family.This 201 to 400 amps(2) $ 96.00 $
property is not intended for sale,exchange, lease,or rent.OAR
479.5400)and 479.5600). 401 to 600 amps(2) $138.50 $
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: Pa.[f). CQf��t.,/.�� C IS.... )j _ /y1G a. Fee for branch circuits with purchase ofa service or feeder fee:
Address: �/ Half '6t .P�(r(&/?rei Js, Each branch circuit $ 6.50 $
City: y[�j,t,� rDY State: Di ZIP: 9 ved b.Fee for branch circuits withom purchase ofa service or feeder fee:
Phone:503 1St/0 1(e7( Fax:5b3769- spec, First branch circuit(2) $ 60.50 $
E-maiCpati.ffccOCtjte,leL-r/ic_Qt.t) y1.Cori Each additional branch circuit $ 6.50 $
CCB license no.: 99333 BCD license no.:074-19 At Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: 3GSs�S• Each pump or irrigation circle(2) $ 69.00 $
Print name of signing supervisor: b;el l� 'Z C Each sign or outline lighting(2) $ 69.00 $
Signature of signing supervisor: ��//�� � �� Signal circuit or a limited-energy panel, $ 80.00 $
signing P effy. t// �`L alteration,or extension(2)
Each additional inspection:(1) $80.00 $
APPLICANT USE
(A) Enter subtotal of above fees /T/
• (Minimum Permit Fee$80.00) $ fo, op
(B)Enter 12%surcharge(.12 x[A]) $ 1%6 a
(C)Technology Fee(5%uf[Al) $ '/ao/
440-2584-J(4/01/2013/COM) TOTAL fees and surcharges(A through C): $ q 3.6o