HomeMy WebLinkAboutPermit Electrical 2013-11-5 cM
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Electrical Permit Application DEPARTMENT USE ONLY
�` +°+ SPRINGFIELD C
•CITY OF SPRINGFIELD, OREGON' :6. s '; Penmtnn.: 513 OZ /
225 Fifth StreettSpringfield,OR 97477♦Pil(541)726-3753•FAX(54t)726-3689 OREGON I
▪r- Date: ////3
# lac.-k_,.; 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.
4.
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? ❑ Yes ❑No Number of inspections per item() Qty. east Total t
CATEGORY OF CONSTRUCTION
Residential,per unit,service included:
°n:a 0 Residential ❑Government Commercial
- - JOB SITE INFORMATION AND LO ATION 1,000 sq.0,or less(4) $147.50 $
e .. Each additional 500 sq.ft.or portion
`Job site address: IISO a 'taw cod 3wd thereof $ 27.60 $
City: caLqn.e- 'Sttate: Olt ZIP; g7A440 Limited energy(2) $ 35.00 $
Reference: )7033 ((J 3 -+ I Taxlo :O gOC Each manufactured home or modular
DESCRIPTION OF WORK dwelling service or feeder(2) $ 69.00 $
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�u) 5-0 amp �tret-e.f- Services or feeders: installation,alteration.relncation 1
200 amps or less(2) $ 89.00 $
PROPERTY OWNER 201 to 400 amps(2) $ 104.50 $
Name: 5 ? . 401 to 600 amps(2) $174.00 $
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:.Address: „ro C1 en.vJ 0 Q 81Va[. 601 to 1,000 amps(2) $225.50 $
City: gene State: OP. ZIP: q141-1-6 Over 1,000 amps or volts(2) $516.00 $
Phone: 54f I - '134.36 Oa Faxs4(- 731, - 36 SO Reconnect only(2) $ 69.00 $
E-mail: Temporary services or feeders: installation, alteration, relncation
200 amps or less(2)
- This installation is being.made on residential.or farm property $ 69.00 $
s,, 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 47.9.5600). 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: ) t-.n5 �l ec.br;e . tyke a.Fee for branch circuits with purchase of a service or feeder fee:
Address: p,O. Box aS - Each branch circuit $ 6.50 $
City: Brow wsv.(le. State: OR. ZIP:g73a1 b. Fee for branch circuits without purchase of a service or feeder f
or
Phone: 5'-(1 -'{fi6-53a6 I Fax: s„E 1 - .464,-SSC D First branch circuit(2) / $ 60.50 $ /
• E-mail: nor ins e_lee&rcQ Lees't-ttry-}el•he t Each additional branch circuit $ 6.50 $
.. CCB license no.: aa•4t.c BCD license no.: 5-SA L•0 Miscellaneous fees:service or feeder not included
35:57 J.Signing supervisor's license no.:. 3 SS 5 Each pump or irrigation circle(2) $ 69.00 $
7L�
Print name of signing supervisor. ?r ajC [ Each sign or outline lighting(2) $ 69.00 $
„J/
f -` Signal circuit or a limited-energy panel,
Signature of signing super ' -/ /� //7 7 alteration,or extension(2) $ 80.00 $
J ...... ✓ Each additional inspection:(I) $80.00 $
:.`_e.. APPLICANT USE
(A) Enter subtotal of ab es
w� - (Minimum Perm- ee$80.00 _ $ So oa
(B)Enter 12%surcharge(.12 x[A]) $ 9 6o
(C)Technology Fec(5%of[A]) $ 4 00
440-2584-J(410112013/C0M) TOTAL fees and surcharges(A through C): $ 93.6,o
SPRINGFIELD CITY OF SPRINGFIELD
225 Fifth St
TRANSACTION RECEIPT Springfield,OR 97477
OREGON 541-726-3753
\
811-SPR2013-02446
www spftngfield-or gov 1650 GLENWOOD BLVD permitcenter@spnngfield-or gov
RECEIPT NO: 2013002429 RECORD NO: 811-SPR2013-02446 DATE: 11/05/2013
DESCRIPTION ' ' Ja cc ouN EreriAilicob E
Balance of Minimum Electrical Permit Fees 224-00000-426102 1004 19.50
Branch circuits without service or feeder-1st circuit 224-00000-426102 1004 60.50
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
r PAYMENT TYRES pAyoR CASHIEFt:DeowLser =COMMENTS . • AMOUNT PAID , I
-
Check norms electric inc 93.60
20120
TOTAL PAID: 93.60
•