HomeMy WebLinkAboutPermit Electrical 2014-1-23 Electrical Permit Application svwruc DEPARTMENT USE ONLY
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CITY-OF SPRINGFIELD, OREGON==
-- Permit no.:S y-co 1rT!
3
225 Fifth Street•Spring0eld,OR 91477,PH(54I)726-3753♦FAX(541)726-3689
Date: l 23 iv
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 Number of per item () Q l inspections , Cost Total
p ea. cost
CATEGORY OF CONSTRUCTION
Residential,per unit,service included:
Residential j ❑Government ❑ Commercial 1,000 sq.ft.or less(4) I 1147.50 $
JOB SITE INFORMATION ND LOCATION
Job site address:
Each additional 500 sq. ft.or portion
thereof $ 27.50 $
'72. 7 S
City: 53 StateCea, ZIP:,7g77 Limited energy(2) $ 35.00 $
Reference: 17)3 3 5-14 Z Taxlot.O 1(00 0 Each manufactured home or modular $ 69.00 $
DESCRIPTION OF WORK dwelling service or feeder(2)
Services or feeders: installation, alteration, relocation
V(�,LV '/� O� "`� 200 amps or less(2) $ 89.00 $
PROPERTY OWNER 201 to 400 amps(2) $ 104.50 $
j Name: c 5,44:0.,Ae(.1 LL 401 to 600 amps(2) $174.00 $
Address: 0 7 s^Z l,11t i.1 a--,�/ 601 to 1,000 amps(2) $225.50 $
City: '1.A. ( State:OIL ZIP: ! 7fla Over 1,000 amps or volts(2) $516.00 $
Phone: Fax: Reconnect only(2) $ 69.00 $
); mail: Temporary services or feeders: installation, alteration, relocation
This installation is being made on residential or farm property 200 amps or less(2) $ moo $
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: El NC TS/Sl QC [CEC71 I (., a. Fee for branch circuits with purchase of a service or feeder fee:
Address: TL S-IS.-21 `,O SC C C (_AN E Each branch circuit $ 6.50 $
City: S PFLO State: 0(Z. ZIP:6\7 u 7 g b.Fee for branch circuits without purchase of a service or feeder fee:
Pbone: -91S" j$..t .3 Fax: -)36- y q 6 0 First branch circuit(2) 1 $ 60.50 $W
E-mail: RDK I/6f `t4N06.(0}n )C ,118
Each additional branch circuit 3
CCB license no.: ( f 7 7 7 0 BCD license no.: .)V -y OS�C Miscellaneous fees:service or fe d e ,e \S N t
Signing supervisor's license no.: 12 2 7 S Each pump' s igatiTOMe .�N\ P ` apolil $
Print name of signing supervisor: 1Z O G FA (t[) N G Each sign or ietoi�� P.� oD��" $ 69.00 $
Signature of sienin supervisor: � Sio al circuit 'z G S el, $ 80,00 $
g alteration,or exteu p . \�'
on1a\N 1 Each additional inspection:(1) $80.00 $
APPLICANT USE
P 0\e5 Gestic. V o'' (A) Enter subtotal of above fees $
{Q � ti1C �1.00.\°.{1 C ' (Minimum Permit Fee$80.00) 17 S .�
v10 20 bt3
, o[S.p`•0{t�ayeotel* l•\' (B)Enter 12%surcharge(.12 x[Al) 5 f f Q
009411�n e Ghe ce`1 6. I
C� t�0 O -b,
�� (C}Technology Fee(5%of[A]) S Z
010bet Gentet TOTAL fees and surcharges (A through C): I $
t ye 4:, '—ff---
440-2584-1(4/01,2013/COM)
SPRINGFIELD C I TY OF SPRINUFILLD
225 Fifth St
`,mss.•- TRANSACTION RECEIPT Spingfield,OR97477
WI- 541-726-3753
.OREGON 811-SPR2014-00143
www.springfield-or.gay 927 A ST 1 perm tcenter W springheld-or gay
RECEIPT NO: 2014000140 RECORD NO: 811-SPR2014-00143 DATE:01/23/2014
DESCRIPTION ACCOUNT CODE/TRANS CODE AMOUNT DUE
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 65.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 15.06
Technology fee(5%of permit total) 100-00000-425605 2099 6.28
TOTAL DUE: 146.84
PAYMENT TYPE PAYOR CASHIER:DBOWLSBY COMMENTS AMOUNT PAID
Credit Card EASTSIDE ELECTRIC INC 146.84
05194g
TOTAL PAID: 146.84