HomeMy WebLinkAboutPermit Electrical 2013-10-28 (2) Electrical Permit Application DEPARTMENT USE ONLY
SPRINGFIELD
CMS SPRANG ID D OO REGOO [V 1: _ g7I -,jP/{d(�13- 021 (7
Permit no.:
225 Fifth Street•Springndd,OR 97477•i'li(541)726-3753•FAX(54l)72636S9 �$OREGON
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. t
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 0 Commercial 1,000 sq.ft.or less(4) $147.50 $
JOB SITE INFORMATION AND LOCATION
W 5 1 1 fl1 '` /A 1 Vet. Each additional 500 sq. ft.or portion $ 27.50 S
Job site address: '�[ thereof
City: Cu(fgym- / State: OA. ZIP: 975403 Limited energy(2) $ 35.00 $
Reference: ' 703 3 CI 33 Taxlot.:(07Oa Each manufactured home or modular $ 69.00 $
DESCRIPTION OF WORK
dwelling service or feeder(2)
«t- (; `Ia- r / �_p Services or feeders: installation, alteration,relocation
CMS.tru�a/I LPG 200 amps or less(2) $ 89.00 $
W PROPERTY OWNER 201 to 400 amps(2) $ 104.50 $
Name: Pa.±.t f Y Q_St' 4 Jp mitt 401 to 600 amps(2) $174.00 $
Address:: IFS kE ( .7 B/UI 601 to 1,000 amps(2) $225.50 $
City: YI l A � State: 04 I( ZIP: q 7403 Over 1,000 amps or volts(2) $516.00 $
V 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) i $ 69.00 $4,1,00
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
479.540(1)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
CONTRACTOR INSTALLATION Branch circuits: new, alteration, extension per panel
Business name: patif c . coast ,, I� it cnc. a. Fee for branch circuits with purchase of a service or feeder fee:
Address: eN�, •E• -tint n .e- Each branch circuit $ 6.50 $
City: , Q,q"Wn State: Die ZIP: 9730 b.Fee for branch circuits without purchase of a service or feeder lee:
Phone:, _q 9-'i f(e ?( Fax:93""3769- Hoe(o First branch circuit(2) $ 60.50 $
L- n
E-mail: pa cie cto a s Le,le 'c_t to 14.CONS Each additional branch circuit $ 6.50 $
CCB license no.: /ice/33 BCD license no.: 2gl-j 9 A . Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: 3GS3S Each pump or irrigation circle(2) $ 69.00 $
Print name of signing supervisor: b(� �t, Each sign or outline lighting(2) $ 69.00 $
Signature of signing supervisor: �,' Signal circuit or a limited-energy panel, $ 80.00 $
Signature b P Ql'/{jj'i//)el alteration,or extension(2)
Each additional inspection:(I) $80.00 $
APPLICANT USE
(A) Enter subtotal of above fees
(Nlinimmn $Permit Fee$80.00) MO
(B)Enter 12%surcharge(.12 x[A]) $ (1,‘,0
(C)Technology Fee(5%of[A]) $ 4v
440-2584-1(4/01/2013/COM) TOTAL fees and surcharges(A through C): $ q3.60