HomeMy WebLinkAboutPermit Electrical 2014-4-22 (2) Electrical Permit Application DEPARTMENT USE ONLY
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r alt } : Permit no.:
225 Fifth SrrcertSpringfreld.OR 97477+P11(541)726-3753$f 1\(541)726 3689 � 9
ON tuO1J
Date: 2Z ( `7
This permit is issued under 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 180 days.
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? ❑ Yes ❑ No Cost Number O bet of inspections per item QIy ea Total
cost
CATEGORY OF CONSTRUCTION
❑ Residential ❑Government I Residential,per unit,service included:
❑Commercial
$
JOB SITE INFORMATION AND LOCATION 1,000 sq. lt. or less(4) $147.50
Job site address://4 7 AIL t 100 sr
Each additional 500 sq. 0.or portion
'_L_ thereof $ 27.50 $
City: cPr:A/ 7,/di/� State: Q� ZIP:q77 7y
/ Limited energy(2) $ 35.00
Referenlj:v!T a. 4 = it a'., ✓ ,.I O. • Each manufactured home or modular
DESCRIPTI•j OF WORK
dwelling service or feeder(2) $ 69.00 S
�� '5 -f�l!� ,Z 7 I .0 //O YS Services or feeders: installation. alrermion. relocation
(J n e� 200 amps or less(2)
2_E rr 4-...,, (� e F"' $ 89.06 $ '�l'/_ •
PROPERTY OWNER 201 to 400 maps(2) $ 104.50 $ �_�.�[
Name: _f4 A ,�n__ -vt-- L . 1,.C, 401 to 600 amps(2) $174.00 • .$
Address: I7N7 Zrw /.�*��: 601 to 1,000 amps(2) $225.50 S
City: ete �� -,#, �S'taate_D� ZIP: G17( Over 1,000 amps or volts(2) $516.00 $
Phone:y/(-74 r .qN Fax: - -
Reconnect only(2) $ 69.00
E-mail: Temporary services or feeders: installation. alteration. relnca ion
This installation is being made on residential or farm property 200 mops or less(2) s 69.00 $
owned by me or a member of my immediate family. This
property is not intended for sale, exchange, lease,or rent. OAR 201 to 400 amps(2)
$ 96.00 $
479.5400)and 479.5600). 401 to 600 amps(2)
$138.50 S
Signature: Over 600 amps or 1,000 volts,sec services or feeders section above
CONTRACTOR INSTALLATION Branch circuits:net. alteration, extension per panel
Business name: ( 1
-B; S Lam. /t G' I j" e a. Fee for branch circuits with purchase of a service or Feeder lee:
Address: x'7 T SC ftJ
{� I'�JC/ ,)/✓ Each branch circuit $ 6.50 S
City: 4)GI ¢ t�. Stare: (.7 r ZIP:,110 81- b. Fee for branch Circuits without purchase of a service or Feeder Ice:
Phone5'Y f / - ti) 1 5 c S o_IFaxS`// 3 J (2)S(� 1� S Pirsl branch circuit(_ $ 60.50
E-mail: Each additional branch circuit $ 6.50 ___._
CCB license no.: 1.3 3 5 r BCD license n0.: Miscellaneous fees:service or_(err/er not included —_
Signing supervisor's license no.: an S Each pump or irrigation circle(2) $ 69.00 ["$
Print name of signing supervisor: ` /l 1 G r z S F Each sign or outline lighting(2) $ 69.00 $
Signature of signing supervise*^\,F=��J cJ✓' shwa]circuit or alimited-energy panel,
$ 80.00 $
r alteration.or extension(2).
Each additional inspection:(I) $80.00 $
APPLICANT USE I
(A) Enter subtotal of above lees f�-t1
(iMinintum Permit Fee$80.00) $ 37 7
(B) Enter 12%surcharge(.12 x I AI) $ `ter
(C)Technology Fee(5%of IAI) $
(4/01/2u13ICOYl) TOTAL 17(5.1-7g-
440-2584-1 fees and surcharges(A through C): $/ 9 -
SPRINGFIELD CITY OF SPRINGFIELD
225 Fifth St
TRANSACTION RECEIPT Springfie1d,06 97477
OREGON. 541-726-3753
811-SPR2014-00873
wwws99969eld-or.gov 1747 MAIN ST permitcenter @spnngfield-or.gov
RECEIPT NO: 2014000883 RECORD NO: 811-SPR2014-00873 ' DATE:04/22/2014
• - •IP 10 S.__T-'f..a j "1.011 ...r `+-.°"`.aft 'ACCOUNT CODE/TRANS=:CODE 'ad.i 'SAMOUNT DUE'
Branch circuits with service or feeder each circuit 224-00000-426102 1004 19.50
Services 200 amps or less 224-00000-426102 1004 356.00
State of Oregon Surcharge(12%of applicable fees) 821-00000-215004 1099 45.06
Technology fee(5%of permit total) 100-00000-425605 2099 18.78
TOTAL DUE: 439.34
PAYMENTAWEEi P.AYOR cnS ri ARPENTERa COMMENTS AMOUNTiPLAID, 7.": ,
Check J&G INV 439.34
1469
TOTAL PAID: 439.34