HomeMy WebLinkAboutPermit Electrical 2013-12-23 fi
Electrical Permit Application DEPARTMENT USE ONLY
trwit„ + iSt7pp n y `-1, n t :er -a- - ,±t SPRINGFIELD
_A'- lTea G I�T++ 272
' ' [J4. , 1771 'll"a7z 4 ° Q ,', .S-r Permit no.:S�� 'Q
225 Fifth Street 1pringlield OR 97477H'I1(540726-3753HA\(541)7263689 -`}-'-!TpriEGaaN
Date: / • 2 3®
1.
This permit is issued tinder OAR 918-309-0000. Permits are nontransferable. Permits expire if work is not started within 180
clays of issuance or if work is suspended for I80 days.
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? ❑ Yes ❑No Number of inspections per item() Qty. Bost eostl
CATEGORY OF CONSTRUCTION
❑ Residential TO Government
Residential,per unit,service included:
' Commercial
1.000 sq.It or less(4) I $147.50 $
JOB SITE INFORMATION AND LOCATION
a Li n
Each additional 500 sq. it or portion
Job site address: 53 ID MaAn S� 9-11-ti thereof $ 27.50 $
City:3 ph n(jBP\d State: 0 g_ ZIP: 6 Limited energy(2) $ 35.00 $
Reference: 70-)2.333 I- Taxlot.o6S'o3 Each manufactured home or modular $ 69.00 ! $
_ DESCRIPTION OF WORK dwelling service or feeder(2) —
Re.p�a ez Comer u g his -f-o LED and Services or feeders: installation,altc/u/on,relocation
200 amps or less(2) $ 89.00 $
' ' ♦ a ! Vail cu—Loo LeY
PROPERTY •WNER 201 to 400 amps(2) $ 104.50 $
[f h
Name: • if •AS ' (Tire C41■40r,5 401 to 600 amps(2) $174.00 $
!
Address: n / 0 yy al-m/ ST— 601 to 1,000 amps(2) $225.50 S
City: SPI= State:p• _ ZIP: / 74 7t," Over 1,000 amps or volts(2) $516.00 S
Phone: - - Fax: - - Reconnect only(2) $ 69.00 $
E-mail: Temporary services or feeders: i a
nato&tion. Iteration. relocation
This installation is being made on esidential or farm property 200 amps or less(2)
r S 69.00 $
owned by me or a member of my immediate family.This 201 to 100 amps(2) $ 96.00 $
property is not intended f o r sale,exchange, lease,or rent.OAR ----
479.540(l)and 479.5600). 4 0 1 1 0 6 0 0 amps(2) $138.50 $
Signature: Over 600 amps or 1.000 volts,see services or Reders section above
_ CONTRACTOR INSTALLATION Branch circuits:new.alieratimr.extension per panel
Business name_SCA\ kAnniCAL a. Fee for bunch circuits with purchase of a service or feeder fee:
Address:Pb }(a 95 Each branch circuit I $ 6.50 Ls
City:ta,}t e (.2-Darld I State: wp- ZIP:Ci spy b. Fee for branch circuits without purchase of a service or feeder fee:
Plhone_3W ( Lf_- c--)80 J Fax3!pb-I( Q W63 First branch circuit(2) —_-1 $ 60.50 $ 66,
E-mail:-.1/v1 h p, A, rnAn .�rr) Each additional branch circuit • yr $ 6.50 $13M
tse t y '� Miscellaneous fees:service orjeeder no included i
C CB license no � (o BCU license no.:
_Signing supervisor's isor's license no.: 5 S/ I Such pump or irrigation circle(2) S 69.00 $
Print name of signing supervisor:--..1 .44, C XX'LS fl Each sign or outline lighting(2) $ 69.00 $
Signal circuit or a limited-energy panel, $ 80.00 s
Signature of signing supervisor: �� alteration,or extension(2)
Each additional inspection:(I) $80.00 $
.(bb€2-ZEE-008-1 8! Jaluao APPLICANT USE
uo!1 o!3poN Am!I!lfl uo6aJ0 all JO!Jegwnu (A) Enter subtotal of above tees
auoyda!al ayl :elON) 'Jaluao ayl 6uillso (Minimum Permit F so_0o) $ 8o
Aq saim sill to se!doo u!elgo hew nod '0600 }}
100 296 b d0 y6noJy3 O WO-1-00-Z96 NVO u! 'B7 � f ?� surchan`c(.12 x A y •' ��
y3JOl has ern soma esoyl 'Jaluao uo!ung!loN (c) e 1 a>� ;. .f . p�L�. ►�rt�iyCl�� i : `{
44(X MN(,iiogzolyco(!n CI paldOpE SOP Mo!!o} �'j •�fig n • r; ,it7.•Y}tii3ill'Sllf; S. go
of no% saarnbaJ MB! uo6aJ0 .NOI1N311V O�,V e,C'' : : ' i
ANY 180 DAY PERIOD. -
SPRINGFIELD'-- CITY OF SPRINGFIELD
225 Fifth St
•
TRANSACTION RECEIPT Springfield,OR 97477
j` 541-726-3753
-'O
OREGON 811-SPR2013-02724
www.springfietd-or.gov 5390 MAIN ST permitcentergspnngfeId-orgov
RECEIPT NO: 2013002725 RECORD NO:811-SPR2013-02724 DATE: 12/23/2013
DESCRIPTION CODE/TRANS:CODE? `_ `?-AMOUNT DfIE.:,
Balance of Minimum Electrical Permit Fees 224-00000-426102 1004 6.50
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 13.00
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
PPAY,MENTi YP.,E PAYORM'cnBNIERaDeouuLS6Y COMMENTS _ AMOUNTiP,AID
Check BELL MOUNTAIN ELECTRICAL 93.60
4572 TECHNOLOGIES LLC
TOTAL PAID: 93.60
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