HomeMy WebLinkAboutPermit Electrical 2013-11-12 Electrical Permit Application DEPARTMENT USE ONLY
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CITY OF SPRINGFIELD, OREGON * Permitne.: S/3• 3 Z 415T-
225 Fifth Strect•Springficld,OR 97477•PH(541)726-3753•FAX(541)726-3689 "� 'T
Date: //// Zj/ ,J
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 O Qty. Cost : Total
-, ...a.: `ea. ,. cost
=-:CATEGORY:OF.,CONSTRUCTION ---_.i__ ----
Residential,per unit,service included:
❑Residential ❑Governmentmercial
, JOB SITE,,INFORMATION 'ANDw LOCATION'. 1,000 sq.e.or less(a) $13a.00 $
3 1 Each additional 500 sq.R.or portion
Job site address: T!/ )-. 5 Sr thereof $ 25.00 $
City'R-I u6-cl CLp State: OIL ZIP: 9 7Q7) Limited energy(2) S 32.00 S
Reference: 1703 z63 Cf Taxlot.:02,70e0 Each manufactured home or modular $ 6100 $
® - DESCRIPTION'OF WORK •r t '• -.,--r- dwelling service or feeder(2)
�• Services or feeders:installation,alteration,relocation
c[ncc (ta'c.crs.- Lt C- rS lu i..,
200 amps or less(2) $ 81.00 $
IL -C-er GFTC-rCtc=t_. Li G a rS
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-, PROPERTY:OWNER ' 201 to 400 amps(2) $ 95.00 S
Name: -rNi4.te. L_L.A.1 401 to 600 amps(2) $158.00 $
Address: L?. S C-&A--, / -57 601 to 1,000 amps(2) $205.00 $
City:Lt"►d tol-atie State:(y`_ ZJP:s,Trr 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 r1r .) Branch circuits:new,alteration,extension per panel
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Business name: J7ELC 1t413t.317&)r7 CL G.criVcd L a.Fee for branch circuits with purchase of a service or feeder fee:
Address: ? g,„ • 5 Each branch circuit S 6.00 $
City:r 4ij,c Csaio>>zo State: (.),4 ZIP:94 c b.Fee for branch circuits without purchase of a service orceder fee: �`
Phone: C,r IScb Fax:at3J (04‘, SoS3 First branch circuit(2) ( $b�00 S 5 G°est
E-mail: 1 cr.sa2c-I i,047•1vs C, wt Each additional branch circuit 9 S 6.00 S4 Ll.
CCB license no.:0621 % I BCD license no.: C--7pa Miscellaneous fees:.service or feeder not included
Signing supervisor's license no.: Sto ,LIS Each pump or irrigation circle(2) $ 63.00 $
Print name of signing supervisorf'f�(Z,y Cn>4/Ln.. no
Each sign or outline lighting(2) $ 63.00 S
Signature of signing supery oT_ LJC,/ Signal circuit or a limited-energy panel, S 63.00 $
alteration or extension(2)
s-1
V\t 05 V\\` Each additional inspection:(I) $58.00 $
\a 1 t(e
OP ekto'th `:.. ,:, .APPLICANT USE Sp
QteQ by\he 0‘.'''ace 52-00 031 (A) Enter subtotal of above fees ? . r$
U Ci r\e . co h t e t e (Minimum Permit F '. ,WJ" %.III
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‘60 pO\\OC\ p1-0 .\a cec'e t\°e\-6 P e,8\,,pP (B)Enter 1.'n I .0 s [ a, 1 $ • -
\A°°\G g51-may °tea. lN°\�rSit 3i V\ • 1�C11d��R � �a.�: •°�°'' �) $
09�•Yo the peg Oce9or 3322 (\a\S POR�1E'10 •P c% i urcharges(A through C): $ /O/
aaoozsnUotelG t e \s�"8��" Pc vi\,.nP e��\00.
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SPRINGFIELD CITY OF SPRINGFIELD
Iiiii. 225 Fifth St
�� TRANSACTION RECEIPT Spdngfeld,OR97477
OREGON 541-726-3753
811-SPR2013-02495
www.springfieldocgov - 1128 5TH ST permitcenter @springgeld-or.gov
RECEIPT NO:' 2013002484 - RECORD NO:811SPR2013.02495 DATE: 11/12/2013
B - - PT ON is.s,`t„*!a.' ' iaa -K. S,A.ree..'w.:4WACCOUNT'CODEJTRANS CODE` F.:°.. :fAMOUNT DUE'Zr
Branch circuits without service or feeder- 1st circuit 224-00000-426102 1004 60.50
Branch circuits without service or feeder-each additional 224-00000-426102 1004 26.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 10.38
Technology fee(5%of permit total) 100-00000-425605 2099 4.33
TOTAL DUE: 101.21
.latMENTISYP.E .P,AYOR .cn r-ga,OEtowrs COMMENTS n AMODNTIP;AID
Check BELL MOUNTAIN ELECTRICAL 101.21
4507 TECHNOLOGIES LLC
TOTAL PAID: - 101.21
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