HomeMy WebLinkAboutPermit Application 2014-1-6 t
Electrical Permit Application DEPARTMENT USE ONLY
SPRINGFIELD
CITY OF SPRINGFIELD, ORGCON Permit no : S/q`OOD/C
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225 Fifth Street•Springlield,OR 97477•Ptl(541)726-3753,FAS(541)726-3689 OREGON
Date: /6 �./
/ I •
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 Numher of inspections per item Qty. Cost Total
CATEGORY OF CONSTRUCTION -
Residential,per unit,service included:
❑Residential ❑Government ®Commercial
JOB SITE INFORMATION AND LOCATION 1,000 sq.0.or less(4) $147.50 $
Each additional 500 sq.0.or portion
Job site address: 300( 1-7-A--(Cf,:,._ thereof $ 27.50 $
City: elk 6--tacr State: CJVZ ZIP: c///7R,� Limited energy(2) $ 35.00 $
Reference: 1703 33 y y Taxlot.OZp00 Each manufactured home or modular $ 69.00 $
dwelling service or feeder(2)
DESCRIPTION OF WORK
Services or feeders:installation,alteration,relocation
Temp Se l-vlaev FOG, r & -r ;IL1 200 amps or less(2) $ 89.00 $
PROPERTY OWNER 201 to 400 amps(2) $ 104.50 $
Name: d D J 7- 401 to 600 amps(2) $174.00 $
Address: `. pq C 4TA_i2V t etc-, -[-N'b o(Q ser 601 to 1,000 amps(2) $225.50 $
City: C rj41,v� StateO4 ZIP: Y'7L0� Over 1,000 amps or volts(2) $516.00 $
Phone: - - Fax: - - :S Reconnect only(2) $ 69.00 $
E-mail: Temporary services or feeders: installation,alteration relocation
This installation is being made on residential or farm property 200 amps or less(2) / ($69.00 �$�
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
479.5400)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: 5,4 n.e. br�.„P. Gs Iecke v e a.Fee for branch circuits with purchase of a service or feeder fee:
Address: -F.0 l3 ' - vie/ Each branch circuit $ 6.50 $
City: Fc.-oc& C°r.,aoc State: Oct.. ZIP:en t)(, b.Fee for branch circuits without purchase of a service or feeder fee:
Phone:%) -357- 0664.1 I Fax€iS-359-owl.. First branch circuit(2) - . $ 60.50 $
E-mail:q`r Cr G Swn,1� IN I•aokat G. •wv'v Each additional branch circuit $ 6.50 $
CCB license no.: 6-714142_ I BCD license no.: '7-44 SC Miscellaneous fees:service or feeder not included
Signing supervisor's license no.: 34 27-5 Each pump or irrigation circle(2) $ 69.00 $
Print name of signing supervisor: G•v1c5-ay-x Lach sign or outline lighting(2) $ 69.00 $
t
Signature of signing supervisor: G 1,r p Signal circuit or a limited-energy panel, $ 80.00 $
�,...� I`.t/v4,.._, alteration,or extension(2)
008 } Si )31 o0lagWnu Each additional inspection:(I) $80.00 $
�bti6Z Z06 uoo9iO au1 gu}(}eo APPLICANT USE •
/won 'ai an ail! _ _ .
uoReoaa'al aUl 14.1-7'a.,01\0 o s. w not OQ�t (A) Enter subtotal of abo• $
qg8\ o%KIDD Ulelq 756 itl (Minimum Permit F e$80.0 t
Aq sap alll} u§ooau10100-100-., U�Ot,40N .- :•. 9d0
Za 6 tia c-t nl asogl 181113 ga}IlA Molloy (B)Enter 12%surcharge(.12 x[A)) E DRS
100 tl0
in/to}1l(� uo6aa0 au1 Aq 0°0°92 J01J_N311 (()(reel 6lhgy Fee(5% [ .�_.1RB ir- ■ as .1.
440-2584-1 l4fOl 1l3/COMt saatnbaJ MCI uo6aJ0 l tl TO! jJ'I a3,� , l e n �%9h?rn'_dt $ -
ol ttur • 1
AUMORIZ i I ' IS ABOD
COMMENCED RER100.
ANY i80 DAY
SPRINSPRINGFIELD CITY OF SPRINGFIELD
GFIELD
AS- 225 Finn St
s
TRANSACTION RECEIPT 225 Fifth St x7477 AR
' � OREGON 541-726-3753
811-S P R2014-00015
www.springfield-or.gov 3001 FRANKLIN BLVD permitcenter @springfield-or.gov
RECEIPT NO: 2014000012 RECORD NO: 811-SPR2014-00015 DATE:01/06/2014
'DESCRIP,TION _ ACCOUNT CODE/TRANS CODE_ - _ • .AMOUNT DUE
Balance of Minimum Electrical Permit Fees 224-00000-426102 1004 - 11.00
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
Temp services 200 amps or less 224-00000-426102 1003 69.00
TOTAL DUE: 93.60
I PAYMENT TYPE - •PAYOR CASHIER:DBOWLSBY COMMENTS_ ___ ___ . _ - AMOUNT PAID-, _ _
. Check SUNDOWN ELECTRIC COMPANY 93.60
5347
TOTAL PAID: 93.60