HomeMy WebLinkAboutPermit Electrical 2007-12-14
2:;5 FlFI1l S rREET . SPRINGFIELD, OR 97477 . PH (54])726-3753 . FAX (~41)726.3689
ELECTRICAL PERMIT APPLICATION
City Job Number C CIA^. ~ C 7 ~O ( S? S-:s:
ZON mrtJ7./
lNlTIALS N ~
DATE I d.-I I, I 0 ..
SOURCE \Y\ '(IS l'" )
Date
IZ-It( -e:.-(
1
3 :~OMPLETEFEESCHEDliLE~Ef!Jij--
,.
LOCATIOl'f OF ll!S~ALIATION:
<) I) 7 A % S-tNe t
LEGAL DESCRIPTION 17C>Z- 333 2 03 11.3 A New ReSldentlal-~SlUgle or ~ultl-Famdyperdwelling UDlL
'S f" '''3 r. € \ d DR. CJ 71.( 7 8 Service Included
JOB DESCRIPTION 1000 sq ft or less
Each additIOnal 500 sq ft or
portIOn thereof
[2t=-PLke
jJ.A-N~L
Permits are non-transferable and expire If work IS
not started wJthm 180 days of Issuance or If work IS
Suspended for 180 days
Each Manufact'd Home or
Modular Dwellmg Service or
Feeder
2
~-~----
, ,
CONTRACTOR Il'fSTALIATION ONLY,
B Services or Feeders - InstallatIon, Alterations or RelocatIOn:
7U
New Alteration or ExtenSIOn Per Panel
One CircUit
Each Addlllonal CirCUIt or With
() Servlce or Feeder PermIt
Owners Name rn'('~H) Ire,l,,\
Address 5 I ~ A S~" ~::J~'{!I ~ ;),HAll :x,,'~II~;lIaneo~:,~servlce/feeder not mcluded) '-E;chIn.tallatlon
City '\I',,^c,\,eld Phonegvffm~DERnl'm'~ rdrt'RK $5500
U ./ 7 7 '/7 f3 COMMENCED OR IS AB~tffl'1 '1;\ J!.1i1MQl $ 55 00
OWNER INST ALLA nON ANY 180 DAY PERIOD. Llmlte~ nefWkesldenllal $ 28 00
The mstallatlon IS bemg made on property I own whIch Lumted EnergylCommerclal $ 50 00
IS not mtended for sale, lease or rent Mmlmum ElectriC PermIt InspectJon Fee IS $50 00 + Surcharges
4 SUBTOTAL OF ABOVE -;7 0
, 8% State Surcharge ;;b=
10% Admmlstratlve Fee -7
5% Technology Fee --<:' ro
&6~
Electncal Contractor 200 Amps or less
201 Amps to 400 Amps
Address 40 I Amps to 600 Amps
601 Amps to 1000 Amps
, ',,\
City Phone ,N ,..,'^~ Over 1000 AmpsNolts
, , - OIJ't~dV'b' law requ~SOl1nect Only
, Y the 0 yOU to
/[, ,,' -e'ller Tho regon Uti I
O ' '/. J01 0 se rul_ Pl.
SupervISor License Number G, 1J y~~_ . 010 throu h ..,.arilllfelV8fi1try Services or Feeders ,
Cq/'/'21t I?~e ~~ uDtam COP/~S o~AR 952-00'.
ExpJratlon Dale nU'l!~t;: lor th^nter (Note th t t~liSlltl!qjt!lf, AlteratJon or Relocation
t7 v Center ~S 0; ~~on UtJ/1tye N~cfIt.!?~S or less
Constr Contr Number 0-332-2344P.O~1J.; to 400 Amps
40 I Amps to 600 Amps
ExprratJon Date
Over 600 Amps or 1000 Volts see "B" above
D Branch CIrcUIts
SIgnature of Supervlsmg ElectriCian
Owners Sf1r'a~ure /J
1YttrJ,4J! C? I~
'~
Inspection Request 726-3769
TOTAL
Shared Dnve(T )/BUlldmg FormslElectncal Permit ApplicatIOn 7-07 doc
$11700
S 2100
$55 00
S 70 00
$ 83 00
$13800
$18000
$413 00
$ 55 00
S 55 00
$ 76 00
$110 00
$ 48 00
$ 400
-~ .,""" ,
CITY OF SPRINGFIELD.
Building/Combination Permit
Status
Issued
225 FIfth Street, SprIngfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 InspectJon Lme
PERMIT NO: COM2007-01853
ISSUED 12/14/2007
APPLIED 12/14/2007
EXPIRES, 06/14/2008
VALUE'
SITE ADDRESS 5137 A ST
ASSESSOR'S PARCEL NO 1702333203113
SprIngfield TYPE OF WORK ElectrIcal Work Only
TYPE OF USE
PROJECT DESCRIPTION Replace 200 amp panel
Owner MICHAEL PERRY
Address 5137 N A ST
SPRINGFIELD OR 97478
I CONTRACTOR INFORMATION I
Contractor Type
ElectrIcal
Contractor
OWNER
LICense
BUILDING INFORMATION'
#ofUmts
PrImary Occupancy Group
Secoudary Occupancy Group
PrImary ConstructIOn Type
Secondary ConstJ uctlOn Type
# of Bedrooms
# of StorIes
R-f\TTENT'Offl~WrfhfW'lu re
follow rules] ~~ at equlres you to
-p\jltltlcat/on CW~ ~ the Oregon Ublity
In OAR 95"-Ooo.(j~(f!!lfce rules are set forth
0090 You m'ljl'1OOJi'41,Jl~u9h OAR 952-001_
calling the CSjl1tllrld(jIJl}.~lq~ the rules &16
number tnr tho '"'__ _. . .... telephone
I~~M~~
Frontydrd Setback
S,de I Setback
SIde 2 Setback
Rearyard Setback
Solar Setbacks
Overlay DlSt
# Street Trees Rqd
Paved D"ve Rqd
0/0 of Lot Coverage
RepdJr
ResidentIal
Phone Number 541- 747-1980
Expiratlon Date Phone
Lot SIze
Sq Ft 1st Floor
Sq Ft 2nd Floor
Sq Ft Basement
Sq Ft Gardge/Cdrport
Sq Ft Other
Occupant Load
REQUIRED PARKING
Total
Handicapped
Compact
I.PUBLIC IMPROVEMENTS I
SldeWdlkjye OR\<.
N01ICE: roaw.J;,'~ ~
11ilS PERMIT SIi"L~ 11ilS PtR m \1101
AUlliORlZED UND~S ABANDONED fOR
~?I~~;~~~~ ~~R\OD.
I ValuatIOn DescnotlOn I
Street Improvements
Storm Sewer Available
Special InstructIOn
Notes
DeSCriptIOn
$ Per Sq Ft
or multJpher
Square Footdge
or BId Amount
TVJle of ConstructIOn
Pa~e I of 2
Value
Date Calculated
Status
Issued '
225 Fifth Street, Sprmgfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 InspectIOn Lme
CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO. COM2007-0]853
ISSUED' ]2/]4/2007
APPLIED: 12/14/2007
EXPIRES' 06/1412008
VALUE'
Total Value 01 ProJect
F~e. PaId I
Amount PaId
Date Paid
Receipt Number
Fee DeSCrIptIOn
+ 10% AdmmlStratlve Fee
+ 5% Technology Fee
+ 8% State Surcharge
Perm ServlFdr 200 amps or less
Totdl Amount Paid
S700
$350
$560
S70 00
12/14/07
12/14/07
12/14/07
12/14107
2200700000000001842
2200700000000001842
2200700000000001842
2200700000000001842
$8610
I Plan ReViews ,
To Request an mspection call the 24 hour recordmg at 726-3769 All mspectlOns requested before 7 00
a,m Will be made the same workmg day, mspectlOns requested after 7:00 a m Will be made the followmg
work day,
I ReoUlred ]nsnec!Jonsl
ElectrIc ServIce Approval required prIor to utlhty company energIZIng servIce
By signature, I state and agree, that I have carefully exammcd the completed apphcatlOn and do hereby certify that all
mformatlOn hereon IS true and correct, and I further certlf) that any and all work performed sh.lIl be done 10 accordance With
the Ordmances of the City of SprIngfield and the Laws of the State of Oregon pertammg to the work descllbed herem, and
that NO OCCUPANCY will be made of any structul e WIthout permISSIon of the CommuDlty ServIces DIVISIOn, Bulldmg Safety
I further certify that only contractors and employees who are m comphance With ORS 701 005 Will be used on thIS project
I further agree to ensure that all reqUIred mspectlons dre requested althe proper time, that edch dddress IS read.hle from the
street, that the permIt cdrd IS located at the front of the property, and the approved set of plans will remam on the SIte at all
hmes dUring construction
Ow,,~,,/ib
Date
\7--;;'-( ~,
/ I
Pa~e 2 of 2
(I)
Construction Contractors Board
700 Summer 8t NE SUIte 300
PO Box 14140
Salem OR 97309-5052
Phone' 503-378-4621
Web Address www ccb state or us
Pemut #
COo/lA C:CCn- () I ~ S- 3
A- ~-l-- /
Date / Z //r;/o7
I /
5/37
I /?
.} '-"-
Address
Issued by
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note Oregon Law, ORS 701 055(4) requIres resIdential constructIOn permIt applicants who are not
licensed wIth the ConstructIOn Contractors Board to sIgn the followmg statement before a bUIldmg
permit can be Issued This statement IS reqUIred for resIdential bulldmg, electrlcal, mechamcal and
plumbmg permIts L,censed archItect and engmeer applicants, exempt from IIcensmg under
ORS 701 010(7), need not submIt thIS statement ThIs statement wIll be filed WIth the permIt
Fill m the appropnate blanks and mll1al boxes 1 and 2, and eIther box 3A or 3B
01
2::(/2
I own, resIde m, or wIll resIde m the completed structure
I understand that I must become lIcensed as a constructIOn contractor If the structure IS sold or
offered for sale before or on completIon
D 3A My general contractor IS
(Name)
(CCB #)
1 will mstruct my general contractor that all subcontractors who work on the structure must be
lIcensed WIth the ConstructIOn Contractors Board
OR
~B I Will be my own general contractor
If I hIre subcontractors, I wIIllnre only subcontractors lIcensed WIth the ConstructIon Contractors
Board In change my mmd and lnre a general contractor, I Will contract WIth a contractor who IS
lIcensed With the CCB and WIll ImmedIately notIfY the office Issumg thIS bmldmg permit of the
name of the contractor
I hereby certify that the above mformatlOn IS correct and that I have read and do understand the InformatIOn
Notice to Property Owners about Construction ResponSibilIties on the reverse Side of thiS form
m:aJj q;?~ (Z-!r~(/u 1
(SIgnature of p"''''': applIcant) / (Date)
(WhIte copy to Issumg agency permIt file, pmk copy to applicant)
Property_owner doc 06-01-04
A_cting as Your Own General Contractor?
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
NOTE This InformatIOn Notice to Property Owners about ConstructIon Responsibilities was developed by the
Construction Contractors Board In accordance with ORS 701 055(5), passed by the 1989 Oregon Legislature
,
If you are actIng as your own contractor to construct a new home or make a substan1::tallmprovement to an eXlstmg
structure, you can prevent many probl'ems by Bemg aware of the followmg responslbll1tIes and concerns
Employer Responsibilities
You WIll, m most mstances, be ruled to be an "employer" and the contractors you contract wIth WIll be "employees" If
you use contractors not hcensed with the ConstructIon Contractors Board to do labor m constrnctIng or to assist m the
constructIOn or Improvem:mt of a reSidential structure As the e~pIoyer, you must comply WIth the following:
Oregon's Withholding Tax Law: As an employer, you must Withhold mcome taxes from employee wages at the time
employees are paid You wIll be hable for the ux payments even If you don't actually WIthhold the tax from your
employees For more mfonna1::ton, call the Department of Revenue at 503-378-4988 ..
Unemployment Insurance Tax: As an employer, you are requrred to pay a tax for unemployment msurance purpose~
on the wages of all employees :or more mformatton, call the Oregon Employment Department at 503-947-1488
"
The Oregon BUSIness Iden1::tficatlOn Number (BIN) IS a combIned nwnber for both Oregon WithholdIng and
Unemployment Insurance Tax To file for a BIN, call 503-945-8091 or ww\v dor state or us/formsoav htmll for the
appropnate forms
Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' CVUOI'~HsatlOn Law,
and must obtam worker~' compensatt,on msurance for your employees If you fall to obtam workers' compensatIon
msurance, you could be subject to penalties and be hable for all claim costs If one of your employees IS Injured on the
Job For more mformahon, call the Workers' CompensatJOn DlVlslOn at the Department of Consumer and Busmess
ServICes at 503-947-7815
U.S. Internal Revenue ServIce' As an employer, you must WIthhold federal Income tax ITom employees' wages '
You Will be hable for the tax payment even If you didn't actually WIthhold the tax For a Federal EIN number, call the
IRS at 1-800-829-4933 or VISIt their web sIte at W'OiW Irs "0\
-
Other Responsibilities and Ar.eas of Concerns
;
Code Compliance. As the penUlt holder for thiS project, you are responsible for resolvmg any failure to meet code
reqUirements that may be brought to your attentton through mspectlons
, ' .
, -
_ {'to _
Liability and Property Dama'ge Insurance: Contact your msurance agent to see' If you have adequate msurance
coverage for aCCIdents and onuSSlons such as fallmg tools, pamt over spray, water damage ITom pIpe punctures, fire or
work that must be redone
- - - . "-
Time' Make sure you have suffiCIent brne to supervIse your employees ,,- r I,
~ \~ . \
Expertise: Make sure you have the slalls to act aq your own general contractor, to coordmate the work of rough-m
and fimsh trades, and to notIfy bUlldmg offiCIals as the appropnate hmes so they can perform the reqUired mspectlOns
If you have addlbonal questIons call the ConstructIOn Contractors Board (503-378-4621) or wnte the agency at PO
Box 14140, Salem, OR 97309-5052
~
Property_owner doc 06-01.04
225 Fifth Street
Sprmgfield; Oregon 97477
541-7~6-3759 Phone
:~
....~
~
City of Spnngfield Official Receipt
Devclopment Scrvlces Department
Public Works Departmcnt
Job/Journal Number
COM2007-0 1853
COM2007-0 1853
COM2007-01853
COM2007-0 1853
Payments
Type of Payment
CredltCard
cReLemtl
RECEIPT #
2200700000000001842
Date 12/14/2007
Description
Perm Serv/Fdr 200 amps or less
+ 5% Technology Fee
+ 8% State Surcharge
+ 10% AdmIDlstratlve Fee
Paid By
MICHAEL PERRY
Item Total
L:heck Number AuthOrizatIOn
Received By Batch Number Number How ReceIVed
dJb 330663 In Person
Payment Total
Page I of 1
9 33 09AM
Amount Due
7000
350
560
700
S8610
Amount P.lld
$8610
$8610
12/14/2007