HomeMy WebLinkAboutPermit Signage 1999-10-29SISN PERMIT APPLICATI''-'
225 Fifth Street
Springf ield, OR 97 477
SP'IINGFIELO J' \UMBER
lnspection Line: 726-3769
Office: 726-3759
SITE ADDRESS
ASSESSOBS MAP:
owNER: F,:,.^-r L-€K-
ADDRESS: \'\'--\ Q ' bOA\a S]<€E-T
TAX LOT:
PHONE:
a
CITY:Oa*=suRG ffi $tfA@STATE:
-Tnr5-rErnwrr
BUSINESS NAME, FIRI\, EEC
DESCRIPTION OF PROPOSED SIGN(S)(please check and complete all appropriate ilft)#rl&$MV FERIOD'
THIS PERMIT IS NOT
Roof _ Marquee
Other
Total Height above Grade:tb'
,* *"u
-
Freestanding
_ Single Face _ Double Face
_ Proiecting
Billboard
Square Footage:lz .k }(
Width of sign or enclosure:t{ I L{1/gtl
IN
Electrical lnstallation: ;{-
(lf yes additional electrical permit is requiredl
Yes _ No VALUE
SIGN:\qqO.cio
List ALL existing signage and attach a photograph of each slgn:
(a) rype R)t€ SqN Sq. Fts . 13,\diE- rur Type
(c) Type Sq. Ftg. (dl TYPe
tVertical Dimension of sign or enclosure:
Dimension from Grade
to bottom of Sign Enclosure:
Material Sign is constructed of:
ter
CONTRACTOR/INSTALLER:LS$/r Stc"xt b Arn:srr t.aG PHoNE:1185 .554to
ADDRESS \2-ro o PFrtCH Q,.!AD
CrrY: aucle$-\P STeTE: OB -ztP: q q q(7
EXPTRES: L- 7-*OICONSTRUCTION CONTRACTORS REGISTRATION NUMBER:\\r?o(
CITY BUSINESS LICENSE NUMBER:ES:
OFFICE USE
Sign District:Land Use:75ro Ouad Area:
a
oL
Zoning ({-Code Section:
I
Approved By:Sign Permit Fee:$r\0,-
REOUIRED INSPECTIONS:
_ Sire
to be made prior
to sign placement
Footing
prior to placement
of concrete
Attachment
after fasteners are
installed/prior to cover
.// zt""rri""t
ffienergizing
electrical installation
DArE: l0 - Rq- a 1
Final
completion of sign
installatiorr
Additional Comments and/or Conditions:
\4-N-
- By signature, I state and agree, that I have carefully examined
ois true and correct, and I further certify that any and all work
Spring tield, and the Laws of the State of Oregon pertaining
employee s who are in compliance with ORS 701.055 will be used on this p roject.
I lurther agree to ensure that all required inspections are requested atthe proper time, that project address.is readable from the street, thi
the permit card is located at the front of the property, and the approved set of plans will remain on the site at all times during the installatio
oJ the sign(s)
n
Date o-\Signature
0 Date Paid:q-g
Amount Received:
)
Validation:
Receipt Number:Received By:
lo-
q t(
I
SIGN PERMIT APPLICATION
The application on the reverse side needs to bo completed entirely. lf you are ths sign contractor/installer, or if you are
hiring a contractor, you need to make sure that both the City of Springfield Buslness License Number and the Begistration
Number from the State ol Oregon Construction Contractors Board are listed on the application along with the expiration
date of each.
lf the sign you are proposing to install is illuminated, an electrical permit application also needs to bo completed and signed
by either a supervising electrician, limited sign electrical contractor, or if you are tho business owner who also owns the
building in which you are occupying, and you will bo performing the electrical installation yourself, you may sign the
electrical application.
lf there are existing wall and/or freestanding signs, a photogroph(s) of oach oxlstlng slgn needs !0 be a.qtEched to tho
applicatlon. The size of each existing sign also needs to be listed on tho qpplication.
PLANS
ITo submit for a sign permit, you need to prepare two complete sets of drawings showing all dinlensions, total height, and
a plot plan indicating where the proposed sign will be located. lf you are installing a freestanding sign which exceeds 20
feet in total height, the footing detail needs to be prepared and stamped by a registerod engineer or architect, After the
plan review process is completed, and, if your sion(s) is approved, one set of plans will be returned to you. The approved
set of drawings need to be at the site when an inspection is requested for the inspectors reference.
INSPECTIONS
Depending on your sign(s), you may be required to request one or all of the following inspections during the installation
of your sign:
Site To be requested after indicating on the lot where the proposed sign will be located but prior to any work
being perlormed for the installation of the sign. This inspection is required if there is a question on the
location of the proposed sign.
Footing: To be requested after excavation and the forms are installed, but prior to pouring concrete. lf there will be
electrical conduit placed in the footing, it must also be in place prior to requesting this inspection.
Attachment: To be requested when all fasteners are installed but prior to cover.
.:
Electrical: To be requested after the electricaltonnection to the sign is made, but prior to energizing.
Final: After all required inspections are condulted and approved and the sign installation is complete.
The inspections that are required for your sign installation will be indicated on the applicatiofr during the plan review
process. Failure to request ANY ol the required inspections could result in sign removal ln orderl to inspect the sion at the
required intervals of work.
To request an inspection, phone 726-3769. This is a 24 hour recording. On the recording you will need tJ, teaJe yopr City
Designated Job Number, location of where the sign is being installed, tho type of lnspection you arC.ibque*3tihi, and when
you will be ready for the inspection. All inspections called in to the recorder prior to 7:OO a.m. wilt be made the same
working day, all inspections phoned in after 7:00 a.m. will be made the following work day.
lf you have any questions regarding the application, required plans or inspections, please feel free to phone the Building
Safety Division at 726-3759
City of SBringtielil
Building Safety Division
225 Fifth Street
Springfield, OR 97477
I
,.
I
(t
Iflltffi'
Ei-'ffif+Btr',
Q /-
CITY OF SPRINGFIELD
APPLICATION FOR DEVELOPMENT COORDINATION APPROVAL
The unders'igned hereby request that the following real property more particul.arly
described Uelow be considered for Development Coordination Approva'l in accordance
with Article l8 of the Springfield Comprehensive Zoning Code.
The applicant must furnjsh the following information:
1) Legal description(s)2) Proof of ownership3) Proof of authority for applicants acting as the owner's agent
Total Land Area: APPr ox. 18,600 sq. -fE.Zoning District:ReEail- Couunercial
Property Location:l-049 Mohawk Blvd.
Springfield, OR 97477
Map 17-03'36-22, Tax Lot l-00Map and Tax Lot #:
Plans Prepared By:Ed Lindskog
Consultine Eneineers, 91T'"E:--hfri?fia?-il-ivd"., La Habra, cA 90631
Telephone #2a3 I 697-7 304
0wner(s ) :Shell 0i1- ComPanY
400 108th Ave. NE,Bel-Ievue, WA 98004 1g1s phone #206 I 4s3-300O
Portland oR 97232
Te1 ephone #
Builder: To be det ernr-ined
Te'lephone #
Description of Intended Use:Midas I'Iuffler ShoP (Sales and installation of automotive
mut t ler /ust svstems, b rakes, shoc k absorbers)
FEES :
Development Coordjnat'ion fees are based on the value of the proiect to be reviewed.
Please check one of the following:
$.l00,000.00 or less valuation Recej ved by
$loo,ooo.oo - $25o,ooo.oo..Date //- /A-a2-
$250,000.00 - $500,000.00... .
$500,000.00 or more.I 50.
I do hereby declare that all plans submitted fulfill and comply wjth all provis'ions
set forth -by Section lB.0l through .l8.07 of the Springfield Comprehens'ive Zon'ing Code.
APPL I CANT :
. Jennings /Iiidas Realty Corporation
$
$
$
$
30.
60.
90.
0000;00-00_
/z-
NAME (p1ea
SiGNATURE:
TITLE: W
se pri
CS rn Estate Mana
ADDRESS: zsss E.Chapman Ave.,
TELEPH0NE: 1jL/s7o-411
Fullerton, CA 9263L
DATE:
FROI4:
TO:
SUBJECT:
PETITIONER:
MAP NO.
LOCATIOI,I:
INSTRUCTIONS:
Springfield Development Coordination Board
4
The Springfie'ld Development Coordination Board w'ill consider the
attached iite ptan at their meeting fxrtl? /2./O'82*7:*4H.
-2
Please check the attached material and subm'it any comments or
'informat'ion deemed necessary for the p ublic benefit to Lorne
VP"
PI r, Building Division sentati ve, n I ater thana<.e .
ADDITIONAL INFORMATION OR COMMENTS :(-
^)
tf Farz o)lt L
eF utJb tlL 6 dD -r4dES
Springfield Bui lding Div'i sion
SIGN
.PERMIT
APPLICATIC''
225 Fifth Street
Springfield, OR 97477
SPFINGFIELO Jr- \,MBE" . qq,qa3
tnspection Line: 726-3769
Office: 726-3759h,
SITE ADDRESS: \ O H
ASSESSORS MAP:
owNER: fOUtrt F P-PHONE:
AD
'CITY: '
BUSINESS NAME, FIRIVI ETC.
\^l -ts_\\
STATE:-i< THIS PEntu[IdHALL ExptRE tFrHE woRK
AUTHORIZED UNDEH THIS PERMIT IS NOT
DEscRlploN oF pnoposED SIGN(s): (prease check and comprete an appropriat. ,";I:,LU"Y
UAY PEHIOD'
X w"lt
-
Freestanding
-
Proiecting
-
Roof
-
Marquee
_ Single Face _ Double Face _ Billboard
-
Other
Square Footaoe:5g .5Kx-I ttt
Vertical Dimension of sign or enclosure:
rl
Dimension from Grade
to bottom of Sign Enclosure:t+t
Material Sign is constructed of:
List ALL existing signage and 8ttach a photograph of each slgn:
(al Type
(c) Type
?orc-\IGN\Sq. Ftg .l3tLpGS=
Sq. Fts.
-No
VALUE
is required)SIGN:5@
uires uto
(bl rype
(d) Type
CONTRACTOR/IN STALLER:S+$V5N PHoNE: +85 -55'+{o
ADDRESS l?-lO Onr*zrcro ?,r^n
CONSTRUCTION CONTBACTORS REGISTRATION NUMBER:
Zl?z q
Z_Z-OIEXPIRES:
EXPIRES:CITY BUSINESS LICENSE NUMBER:(o -3.D -oo
OFFICE USE
Land Use:
I
Szoa Ouad Area:JoulJSign District:
Zoning:(-o Code Section
I
Approved By:Sign Permit Fee
BEOUIRED INSPECTIONS:
__ Site
to be nracie prior
to sign placement
Footing
prior to piaceinent
of concrete
-/Attachrnent
il'.er fast"ners are
installed/prior to cover
a-)
u--Electrical
prior to energizing
electrical installation
Final
cornpletion cf
installatiort
DATE:
t
Additional Comments and/or Conditions:
- By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all information hereir
is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances o, the City o
Springfield, and the Laws of the State ol Oregon pertaining to the work described herein. I further certify that only contractors an'
employees who are in compliance with ORS 701.055 will be used on this project.
I further agree to ensure that all required inspections are requested at the proper time, that project address'is readable from the street, th.
the permit card is located at the f ront of the property, and the approved set of plans will remain on the site at all times during the installatio
of the sign(s).
DateSignature
a- <iAmount neceived: d 55.
-
Pate Paid:Validation
Receipt Number:Beceived By:
o
Total Height above Grade:
I
of sign or enclosure: L3t 3u
follow rules adoPted'by the
set forthNlotificationThoserules are
in OAB through oAR 952-001-
0u9u. You by
calling (Note: the
numberfor
crv: Eq-rQa€)\)€- STATE: oB
$sa. -l0 -91- 1c?
\O- \r+-9ar
DVbh< I
SIGN PERMIT APPLICATION
The application on the reverse side needs to be completed entirely. lf you are the sign contractor/installer, or if you are
hiring a contractor, you need to make sure that both the City of Springfield Business License Number and the Registration
Number from the State of Oregon Construction Contractors Board are listed on the application along with the expiration
date of each.
lf the sign you are proposing to install is illuminated, an electrical permit application also needs to be completed and signed
by either a supervising electrician, limited sign electrical contractor, or if you are tho business ownor who also owns the
building in which you are occupying, and you will be performing the electrical installation yourself, you may sign the
electrical application.
lf there are existing wall and/or freestanding signs, a photogroph(s) of each exlstlng slgn needs lo be attached to the
applicatlon. The size of each existing sign also needs to be listed on tho Spplication.
i
PLANS
To submit for a sign permit, you need to prepare two complete sets ol drawings showing all total height, and
a plot plan indicating where the proposed sign will be located. lf you are installing a sign which exceeds 20
f eet in total height, the footing detail needs to be prepared and stamped by a registered engineer or architect. After the
plan review process is completed, and, if your sign(sl is approved, one set of plans will be returned to you. The approved
set of drawings need to be at the site when an inspection is requested for the inspectors reference.
INSPECTIONS
Depending on your sign(sl, you may be required to request one or all of the following inspections during the installation
of your sign:
Site: To be requested after indicating on the lot where the proposed sign will be located but prior to any work
being performed lor the installation of the sign. This inspection is required if there is a question on the
location of the proposed sign.
Footing: To be requested after excavation and the forms are installed, but prior to pouring concrete. lf there will be
electrical conduit placed in the footing, it must also be in placo prior to requesting this inspection.
Attachment: To be requested when all fasteners are installed but prior to cover.
..:
Electrical: To be requested after the electricaltonnection to the sign is made, but prior to energizing,f
iFinal: After all required inspections are conducted and approved and the sign installation is complete.
The inspections that are required for your sign installation will be indicated on the applicatioh during the plan review
process. Failure to request ANY of the required inspoctions could result in sign removal in ordorl to inspect the sign at the
required intervals of work,
To request an inspection, phone 726-3769. This is a 24 hour recording. On the recording you will need to leave your City
Designated Job Number, location of where the sign is being installed, the type of inspection you are.rsquesting, and when
you will be ready for the inspection. All inspections called in to tho recorder prior to 7:00 a.m. will be made the same
working day, all inspections phoned in after 7:00 a,m. will be made the following work day.
lf you have any questions regarding the application, required plans or inspections, please feel free to phone the Building
Safety Division at 726-3759
City of Springtield
Building Safety Division
225 Fitth Street
Springfield, OR 974117
l
,.
I
SIGN PERMIT APPLICATII^_'
225 Fifth Street
Springf ield, OR 97 477
SPRINGFTELc,JT \UMBER Q1 t\t n
lnspection Line: 726-3769
Office: 726-3759
SITE ADDRESS:
ASSESSORS MAP:
OWNER Qrr^:eF-€PHONE:
\\n u-) . '?zDrcrE sr=€ET
TAX LOT:
ADDRESS:
a
CITY:
-hosEr5\,\RC1
STATE:AUI
rcnM[sF,ArtErPt
BE IF THE WOBK
COMI4ENCED OB
IS NOT
BUSINESS NAME, FIRIVI EEC.
DESCRIPTION OF PROPOSED SIGN(S): (please check and complete all appropriate information)
X w.rr
-
Freestanding
-
Prolecting
-
Roof
-
Marquee
_ Single Face _ Double Face _ Billboard _ Other
Square Footage:b
Vertical Dimension of sign or enclosure:Z \t
Dimension from Grade
to bottom of Sign Enclosure:t+t ,
Material Sign is constructed of:
Total Height above Grade:
Horizontal Width of sign or enclosure:\ot L{ \l
Ito'
VALUE
OF SIGN:\ q3o.eElectrical lnstallation:
additional electrical permit is required)
X Yes No
List ALL existing signage and attach a photograph of each slgn:
(al Type .l3.uu\.{b} Type
(c) Type
toiisw rr.iies adcpte0 by the Oregon Utility
I-lotification r. Those rules are set forth
n OAR 0 10 through OAR 952-001-
uugtrYoLl may rules by
(d) Type c?rt,iit1i; i$q.cnt$et. r.irl'ote: the t hone
,rumBer for the Cregon Utiliiy Notification
Sq. Ftg
Sq. Ftg
veilter r5 | "(JUU15,52-ZJ4+t.
PHoNE: +e6: 55'ltCONTRACTO R/I N STALLER:&\
ADDRESS tuo 6n lFrre{ A 12r-166
CONSTRUCTION CONTHACTORS REGISTRATION NUMBER:
ZI?:
EXPIRES:
EXPIRES:
L-L- Or
CITY BUSINESS LICENSE NUMBEB:
OFFICE USE
Sign District:Land Use:5zo'o Ouad Area
Code Section:,( .a4Y t t\Zoning:fl
Sign Permit Fee:
REOUIRED INSPECTIONS:
.- Site
to be made prior
to sign placement
Footing
prior to placement
of concrete
Approved By:
V Attachment
IiiE-r fast"ners are
installed/prior to cover
Electrical
pricr to s6srgizing
electrical installation
DArE: lD - Lq - 4, I
Final
completion of sign
installatiorr
Additional Comments and/or Conditions:QUTIMJ hpwtui fur*nlvA ,rui- h ;' q-u-"*'n-
,- By signature, I state and agree, that I have carefully examined the compleied application and do hereby certify that all information
is true and correct, and I further certify that any and all work performed shall be done in accordance with the Ordinances of the City o
Springfield, and the Laws of the State of Oregon pertaining to the work described herein. I further certify that only contrsctors ?n,
employees who are in compliance with ORS 701.055 will be used on this project.
I further agree to ensure that all required inspections are requested at the proper time, that project address.is readable from the street, thr
the permit card is located at the f ront of the property, and the approved set of plans will remain on the site at all times during the installatio
ol the sign(s).
Signature Date \& \4 c/ a
Validation
Receipt Number:
* *tt
Received By:
Date Paid:61- ti
crD\e- S\o,ra
I U
ctrY: A\lGe(..-g sr,tre: OI\
I r ,7_Qt-
Amount Received:
SIGN PERMIT APPLICATION
The application on the reverse side needs to be completed entirely. lf you are the sign contractor/installer, or if you are
hiring a contractor, you need to make sure that both the City of Springfield Buslness License Number and the Registration
Number from the State of Oregon Construction Contractors Board are listed on the application along with the expiration
date of each.
lf the sign you are proposing to install is illuminated, an electrical permit application also needs to be completed and signed
by either a supervising electrician, limited sign electrical contractor, or if you are the business owner who also owns the
building in which you are occupying, and you will be performing the electrical installation yourself, you may sign the
electrical application.
lf there are existing wall and/or freestanding signs, a photograph(s) of each existing sign needs to be attached to ths
applicatlon. The size of each existing sign also needs to be listed on the epplication.
PLANS
I
To submit for a sign permit, you need to prepare two complete sets ol drawings showing all diniensions, total height, and
a plot plan indicating where the proposed sign will bo located. lf you are installing a freestanding sign which exceeds 20
leet in total height, the footing detail needs to be prepared and stamped by a registered engineer or architect. After the
plan review process is completed, and, if your sign(s) is approved, one set of plans will be returned to you. The approved
set of drawings need to be at the site when an inspection is requested for the inspectors reference.
lNSPECTIONS
Depending on your sign(s), you may be required to request one or all of the following inspections during the installation
of your sign:
Site To be requested after indicating on the lot where the proposed sign will be located but prior to any work
being performed for the installation of the sign. This inspection is required if there is a question on the
location of the proposed sign.
Footing: To be requested after excavation and the forms are installed, but prior to pouring concrete. lf there will be
electrical conduit placed in the footing, it must also be in place prior to requosting this inspection.
Attachment: To be requested when all fasteners are installed but prior to cover.
Electrical: To be requested after the electricaltonnection to the sign is made, but prior to energizing.
Final: After all required inspections are condulted and approved and the sign installation is complete.
The inspections that are required for your sign installation will be indicated on the applicatiofr during the plan review
process. Failure to request ANY of the required inspections could result in sign removal in orderl to inspect the sign at the
required intervals of work.
To request an inspection, phone 726-3769. This is a 24 hour recording. On the recording you will need to leave your City
Designated Job Number, location of where ths sion is being installed, the type of inspection you ar€ requesting, and when
you will be ready for the inspection. All inspections called in to tho recorder prior to 7:00 a.m. will be made the same
working day, all inspections phoned in after 7:00 a.m. will be made the following work day.
lf you have any questions regarding the application, required plans or inspections, please feel free to phone the Building
Safety Division at 726-3759
City of Springtietd
Building Safety Division
225 Fifth Street
Springfield, OR 974i17
I
I
,.
I
SPFIIIGFTELE'
ZiJiti^ij and dOeS not require specific land use€
''1Pi-rl0Vai
225 FIFTB STREEf, Zonins
SPRINGETEID, OREGON
INSPECTION REQIIBST:
97477
0FFICB: 726-3759 4d'.rlurrruu Srgnatrrre
1. I.OCATION OF INSTALI,A:TION
loqq H ts{A\^JK BUv S.
C-PEru{TT APPLICATTON
City Job
3. COHPLETB FBE SCEEDT'LE BEIOS
A Nev Residential-Single or
Hulti-Family per dvelling unit.
Service Included:Items Cost
c
D.
E
5. SUBTOTAL OF ABOVE
?Z state Surcharge
3% Administrative Fee
TOTAL
I o lao Sum
JOB DESCRIPTION
StGtr\N\S;Tta\-1.
Permits are non-transferable and expire
if vork is not started vithin 180 days
of issuance or if vork is suspended for
180 days.
2. CONTRACf,OR INSTALI,ATION ONLT B
EIec trical Con tractor LSth STqNIAI^:ST Nq
Address lZlO K PlqTI. -H C\
Ci ty tr N€Phone +85 .559tP
Supervisor License Number 2O' 255e-L=
1000 sq. ft. or less
Each additional 500
sq. ft or portion
thereof
Each Manuf'd Home or
Modular Dwelling
Service or Feeder
$ 8s.00
s 1s.00
$ 40.00
Services or Feeders
fnstallation, Alterations
or Relocation:
200 amps or less
20L amps to 4OO amps
-401 amps to 600 amps _
601 amps to 1000 amps-
Over 1000 amps/volts
Reconnect 0nly
Temporary Services or Feeders
Installation, Alteration or Relocation
200 amps or less
201 amps to 400 amps _Over 401 to 600 amps
Over 600 amps or 1000-6[Ts
Branch Circuits
ee rrBtt a6ove
Nev, Alteration or Extension Per Panel
One Circuit $ 35.00
Each Additional
Circuit or vith Service
or Feeder Permit
-
$ 2.00
Miscellaneous (Service/feeder not included)
-Each installation
Pump or irrigation
Sign/Outline Light
Limi ted Energy/Res
Limited Energy/Comm
s s0.00
$ 60.00
s100.00
s130.00
s300.00
s 40.00
Expiration Date
Constr Contr. Number \tlLBLfr
Expiration Oate- L- L - OI
Signa ture of sing Electrician
Ovners Name Fa'i r)tF?
Address
ci tv'R)s€EI-rP(-q Phone
OVNER INSTALI.,ATION
The installation is being made on
property f ovn vhich is not intended
for sale, Iease or rent.
Ovners Signature:
DATE:
t-
40.00
55.00
-80.00
s
$
$
s
s
$
$
s
00
00
00
00
40.
40.
20.
36.
D0gi"sW
(.r[D
3{.BJt"-l(. sD
CITY OF SPR
RECEIVED
lo'>.'r q'l
b).-
Zoning
225 FIFTB STREEf,
SPRINGFTELD, oRBcCI0tg
INSPEGIION REQI Es1drtho?86#g060ure
OFPICE: 726-3759
1
lrt txft' tn
I.EGAL
SI 'GFIELO
t
ET,ECTRIC.A,L PERffiT APPLICATION
City Job Nurnber
3. COHPI.ETS FEE SCBEDT'I,E BELoV
A.Nev Residentlal-Single or
Hu1ti-Family per dvelling unit.
Service fncluded:Items Costloo Sum
JOB Ns
t80
000 sq.ft. or less
additlonal 500ft or portion
Ins tallat i oll Ior Relocation:
'd Home. or
-
lons
s 85.00
$ 15.00
$ 40.00
t'
*qro S0perruits are non-transferable and exp
lf gork is not started vithin 180
of lssuance or if vork is suspended
180 days. ,.
2. CONTRACf,OR INSTALI,ATION O}ILT
Erectricar contractor L'R' Brabham, Inc'
Address 68 t{est "Q" Street
ct Springfield phone 747-6638
I
200 amps or less t
201 amps to 400 amps
-401 amps to.600 amps
601 anps to 1000 amps_
Over 1000 amps/vo1ts
Reconnect Oniy
D.<y
.B
I 4735
L/tJv,00
00
00
00
00
00
$s0
$60
s100
$130
$300
$40
Constr Contr. Number 08699
Exp irati.cn Date 12/18/aO
Slgnat of Supervising Electrician
Address 3/04 ttt &E
cl q fi tPhone t7q7 One Circuit S 35.00
Each Additional
Supervisor License Number
Expi ration Date 10101/At
Ovners ame
OIINER TNSTALTTTION
OvnerS*signature:
DATE:
The installation ls being made onproperty I ovn vhibh is not intendedfor sa1e, lease or rent.
C. Temporary Services or Feeders
Installation, Alteration or Relocation
200 amps'or less $ 40.00
over 401 to 600 amps
-
g 80.00
0ver 600 amps or r0OOT6T[s see nB, a56iE
D. Branch Circul ts ) ..
Nen, Alteration or Extension Per Panel
5. SUBTOTAL OP ABOVE
/ //, State Surcharge
3Z Admtnistratlve Fee
TOTAL
Circuit or vith Service ,;;-r;;j"i-p"irit--- --- / $ 2.oo Z,oc'
E. Hiscellaneous (Servlce/feeder not included)
-Each installation
Pump or irrigation SSign/Outllne Llghtingl- S
Limlted Energy/Res $Limited Energy/Comm S
40.00
40.00
20.00
36.00
Z
RBCEIVED
a.r:. .:. ,,C|TY.t.)