HomeMy WebLinkAboutPermit Building 1999-04-16SPF!lrlGFIELD
225 North Fifth Street
Springfield, OR 97477
Location of Proposed Work:. 179 14TH ST
Assessors Map #: 1-'7033532
Page 1
COI$TERCIAL/ INDUSTRIAI, PERMIT APPLICATION
CITY OF SPRINGFIELD ilob Number: 981491
COMMI'NITY SERVICES DIVISION
BUILDING SAFETY
office
Inspection Line
726 -37 59
726 -37 69
Tax Lot #: 04400
SPruNGFIELD
Owner: SR YETT
Address: PO BOX 261-25
Description Of Work: REMODEL
Phone #: 344-6781-
city/state/zip: SPRTNGFIELD, OREGON 9747
NEW VaIue 1, 000 . 00
General:
Plumbing:
Mechanical:
Electrical-:
ConEractor
GATE CREEK CONS 0074777
621- F Street Springfield OR 9747700
DICK BATLEY 0107255
92830 COBI]RG RD EUGENE OR 9740894L2
GARIBAY 0043251.
4207 W 5th Eugene OR 974020000
C S ELECTR]C OO541O5
1024 NE DAVIS PORTLAND OR 97232OOOO
Const.
Contractor #Expires
01,/L1,/e8
06 /2e / e8
L2/O!/eO
o8/03/eB
Phone
844-7 A66
344-6996
344-248].
234-661,7
--- PLIIMBING ---
No
1
Fee Charge
15.00
15.00
Sj-ng1e Fj-xture
TOTAT PERMIT
QUAD AREA: 1CSE
-- OFFICE USE --
LAND USE: 5300
Item
MINOR ADDITION
TOTAL VALUE OF PRO.'ECT
Square Feet
84
x $/Square Feet VaIue
4 ,20O . O0
4 ,200 .00
BUILDING
Surcharge/Admin
MECHANTCAL
Surcharge/Admin
PLUMBING
Surcharge/Admin
CITY SDC FEES
SUBTOTAL PERMTTS
50
4
0
0
15
1
108
.50
.05
.00
.00
.00
.20
.58
L1 9.33
TOTAL PERMIT FEES EXCLUDING ELECTRICAL L7 9 .33
SPlr!NGFIELD
rfob Number: 981-491 Page 2
REQUTRED TNSPECTTONS
It is the responsibility of the permit holder to see that afl j-nspections are
made at the proper time. To reguest an inspection, cal-l 726-3769(recorder), state your City designated job number, job address, type of
inspection requested and when you wj-11 be ready for inspection. Requests
received before 7:00 a.m. wi-l1 be made the same working day, requests made after
7:00 a.m will be made the following work day.
Special Inspections: In accordance with Section 305 of the State Specialty Codea speciar inspector shal1 be employed by the owner/contractor during
construction of any following "*" work. A copy of t.he special testing reportsshall be furnished to Building Safety.
In addition to the inspections specified, the Building Official may make orrequire other inspections of any construction work to ensure compliance withthe Building, City or Development Code.
ROUGH PLITMBING - Prior to cover.
ROUGH ELECTRfCAL - Prior to cover.
FRAITING - Prior to cover.
INSUL-V,B./SUB: TO BE CALLED FOR AT SAME TIME AS SUB FRAMING fNSPECT
DRYITIALL - prior to taping.
FrNAL FrRE - when aIl- Fire Department requirements have been met.
been met.
FrNAL srrE PLAT.I - After all requirements hawe been met for Minimum
Development standards or from the Deveropment Agreement.
FrNAL BUTLDTNG - when all required inspections have been approved andthe buil_ding is complete.
MDS REVIEW BY JULTE SCOTT
Plans
Building Site Reviewed By
ADDITTONAL COMMENTS
Reviewed By: LORNE PLEGER Date: 02/a2/99
By signature, I
application and
state and agree, that r have carefully examined the completeddo hereby certify that all information hereon is t.rue andcorrect, and f further certify that any and all work performed sha1l be d.onein accordance with the ord.inances of the city of springfield, and the Lawsof the state of oregon pertai-ning to the work d.escribed herein, and thatNo OCCUPANCY will be made of any structure without permission of the
Communi-ty Services Division, Building Safety. I further certify that onlycontractors and employees who are in compliance with ORS 701.055 wi1l beused on thls project.
r further agree to ensure that al-I required. inspections are requested at theproper time, thaE projecE address is readable from the street, that thepermit card is located at the front of t.he property, and the approved setof plans will remain on the site at alr times during construction.
4-lU+1QitureDate
SPRINGFIELD
Job Number: 98149l-
OF SPilNGFIELT',
Page 3
Receipt Number:
Date Pai-d:
Amount Received:
Received By:
--- VALIDATION ---
^7fl=
L)n .QQ
a
1-he followrng project as submitted haszonrng and does not require specificapproval
Zoning
Date
the following
land use
Multi-Family
Service Inclu
SPFTINGFIELE,
BLECIRICAL PERHIT APPLICATION225 FIFTE STREET
spRrNGFrELD, OREGOf grP4?9o signature
INSPECTION REQUEST: 726-3769
OFFICE z 726-3759
INSTALLATIq^y 0N-Ar*1. LOCATI OFON
5
Ci ty Job Nurber
3. COHPLETE FEE SCBEDTILE BELO\{
A. Nev Residential-Single or
?il,/1r
er dvelling uni t.
ed:
I tems Cos t
p
dLEGAI DESCRIPTIONb 7z o /{o o
JOB
Perif
of
2.
Electrical Contractor
Expiration Date lO - | -QB
Constr contr. Number 3*,49
Expiration Date q -l -lpc>O
Signature of Supervising Electrician
Ovners Name 5.K.b
Address /.0 lh v Lf,r z{
Ci ty Phone 3v,{- L7 t /
OVNER INSTALLATION
The installation is being made on
property I ovn which is not intended
for sale, lease or rent.
Owners Signature:
DATE
1000 sq.ft. or less
E ional 500
portion
E
ANY 180B. Service
Installation, Alterations
or Relocation:
200 amps or less
201 amps to 400 amps ---
401 amps to 600 amps _601 amps to 1000 amps_
0ver L000 amps/vo1ts
Reconnect Only
C
One Circuit
Each Additional
Circuit or vith Servic
or Feeder Permit
Temporary Services or Feeders
Installation, Alteration or Relocation
Sum
s 8s.00
eaaress P. O. ft4 ltlgl-,
ci,vQ+i1rq[*\d* vhone 141- l.LZ b
Superviso. Lro&nse Number lb f bS
50.00
60.00
100.00
40
130.00
300.00
00
00
s 1s.
WORK
s
s
s
s
s
$
s
s
s
s
200 amps''or less $
201 amps to 400 amps
-
$
over 4()L to 6oo amps
-
$
Over 600 amps or l,OOOTdITs se
00
.00
.00
.00rrgtt uffir!-
D. Branch Circuits
Nev, Alteration or Extension Per Panel
t $ 3s'oo 9J--
3 g2.oo b
40
55
BO
e
40.00
40.00
20.00
36.00
,00
E. MiscelLaneous (Service/feeder not included)
-Each installation
Pump or irrigation
Sign/Outline Lighting-
Limited Energy/Res
Limited Energy/Comm
SUBTOTAL OF ABOVE
5Z State Surcharge
3% Administrative Fee
TOTAL
5
RECEIVED
\
/7a
180 daygfllling the
numberforthe
Md6trb
'^'TRNAL oR JoB No . 7D//? /
ATTACHMENT A
CITY OF SPRINGFIELD SYSTEMS DEVELOPMENT CHARGE
l^lORKSHEET
NAME OR COMPANY:
LOCATION /77 e. /r &_
DEVELOPMENT TYPE , I /J" lJJ,^/,b/.
AJJ,'{ri,n
BU.IIDfNG SIZt:
v/ltuao LOT SIZE SQ. Fto/;F
1 XJ N
ac,
IMPERV]CUS SQ. FT
l'4I^Jl.4C CREDIT iF APPLICABLE (SEE REVERSI)
MI,,/MC ADMINISTRATiVE FEE
/424.r' 6-r€a ! ,lr,C,// of az,u*,anntnJ 6r*eZce^:yr/tz
2. SANITARY STWER-CITY - rIZ Aa..u ,F,Vr'r,r"-s
NO. OF PFU'S X S47. 14 PER PFU
(See Reverse Side)
3. TRANSPOR IAIION
NO OF UNITS X TRIP RATE X COST PER TRIP
"ogy' x ,.p. f,?x L1L/\ 1/
x $475.32
X $0.227 PER SQ FT. S@
TOTAL-MWMC SDC
SUBTOTAL (ADD ITEMS 1.2,3 & 4)
s.+
tr/
$ ,/o 3
X $
4. SANITARY SEI,JER-MI^/['4C
A. REIMT|JP.STMENT COST:
NO. OF FEU 'S .O2? r AUA%'R FEU
B. II\4PROVTMENT COST:
No. oF FEU',S .0g/ X EpER FEU
$ /7 q'b
€. $ ,4G
$ 10.00
7-i-c-
c
5 ADMINISTRAT IVI] FEES
BASE CHARGE (SUBTOTAL ABQVE) X .05
S
ATTACH 'A. WPD
i nator
Date
TOTAL SDC $ /oa ^-D9L--
s /,-f7
$,5-z
?,i
FIXTURE UNIT CALCUL'-loN TABLET Number or New Fix.
(NOTE: For remodels. calculate only -e NET additional fixtures)
FrxruRE rYPE ily,X?iXrffirt
' X Unit Equivalent = Fixture Units
UNIT
EOUIVALENT
FIXTURE
UNITS
Bathtub......
Drinking Fountain....
Floor Drain.
lnierceptors For Grease/OiliSolids/Etc
lnterceptors For Sand/Auto Wash/Etc
Laundry Tub/Clotheswasher...
Clotheswasher - 3 Or More.....
Mobile Home Park Trap (1 Per Trailer)............
Receptor For Refrigerator/Water StationiEtc....
Receptor For Cornmercial Sink/Dishwasher/Etc
Shower, Single Sta11..........
Shower, Gan9........
Sink: Bar, Commercial. Residential Kitchen......
Urinai, Stall/Wall...
Wash Basinilavatory, Single.
Toiler, Public lnstallation.
Toilet, Private......
Miscellaneous:
TOTAL FIXTURE UNITS
CREDIT CALCULATION TABLE: Based on assessed value. lf improvements occurred after annexation date in table,
calculate credits se a rate s
2
1
2
3
6
2
b
6
1
3
2
l lHead
2
2
1
b
4
Year
Annexed
Rate per $1,O00
Assessed Vaiue
9s-
€:{
^ - Q-,=$ i(.G-
a
Credit for Parcel or Land Only lf Applicable
lmprovement (if after annexation date)
1;z x$/L
(Rate X Assessed Value) ..7a><>
X$
(Rate X Assessed Value)
CREDIT TOTAL
1 981
1982
1 983
1 984
1 985
1 986
1987
1 988
4.18
4.12
3.99
3.83
3.68
3.48
3.18
2.82
2.42
1 979 or befo $4.27
Rate per S1,000
Assessed Value
Year
Annexed
1000
'1 00n
1 001
'l 992
1002
1 994
1 00q
1 004
1 001
$1.98
1.55
1.15
0.96
0.83
0.67
o.52
0.38
o.21
d/./t lll/.- ty'7i$zao RUNoFF coEFFrcrENTS FoR sroRM DRATNAGEq-
,,jcn/, 6-,-aL -- C5'r/28-f, (For Estimating Purposes onlyl
> /, $1il^€a Residential..
= ( ge Zoo /), *Eomme,ical.......'.....
7ir-e s-/ - sv - )L' c rtldustri a l' "''' -'/ / '-bovernmental...,......
droui/,-/u n
o.4
0.9
05
o.5
FIXUNIT.WPD IMPEBVIOUS AREA = TOTAL LoT SIZE X RUNOFF COEFFTCIENT
C'TY OF OREGON
SPT'INGFIELC'
%
eporcval
97 477
126-37
Autnorlzeo Signature
1.LOCATION OF
LEGAL DESCRTPTION
JOB DESCRIPTION
Permits are non-transferable and expire
if vork is not started vithin 180 days
of issuance or if vork is suspended for
1B0 days.
2. CONTRACTOR INSTALI.,ATTON ONLY
Electrical- Contractor
Address P.O. Box 21 009
The lotlowing Proiect as submitted has the
zoning. and does not specilic land use
Date
BIJ TRICAL PERHIT APPLICATION
ci Job Number
SCHEDTII,E BELOIi
A. Nev Residential-Single or
Multi-FamilY Per dvelling unit'
Service Included:ftems Cost
L000 sq.ft. or fess
Each additional 500
sq. ft or portion
thereof
Each Manuf'd Home or
Modular Dvelling
Service or Feeder
s 8s.00
$ 1s.00
$ 40.00
ATEE NTgANtQrogondawEeqdhes you to
nls
forth
oAR 952-001-0010 h oAR 952-001-s s0.00
s 60.00
$100.00
s130.00
s300.00
s 40.00
You EfiHfr the ru l€s-by-
f,IEP
2,25 FTFiTB STREBT
SPRINGFIELD, OREGON
INSPECTTON REOTIEST:
oFFICE: 726-3759
City Eu ene
calling
Phone 461 -5678 number
C
Sum
Supervisor License Number \LOaAFerI
Expiration Date
Constr Contr. Number 65149
Expiration Date 6-28-00
Signatu of ising Electrician
.ZrOvners Namel)i\rR-n 'q P++
Address Ilq \r*tb -st
Temporary Services or Feeders
fnslallation, Alteration or Relocation
200 amps or fess $ 40.00
over 4bi. to 6oo amps
-
S 80.00
Over 600 amps or fbOO voTts see uB' a666
Branch Circuits
Nev, Alteration or Extension Per Panel
r tS
Reconnect 0n
One Cireuit
Each Additional
Circuit or vith Service
D
$35.00
2.00
not in cluded )
@
Ci ty Ph.ftift#&-r6L
OVNER INSTAILATION or Feeder Permi t
rhe ins talrat ion is beintulHoeiffiD TJNDER rift pCsliffihnt::li"Ii:ilt"e/reeder
property I ovn vhich is pgtrr.{fSended " -' -:!
ior'sarl, rease or-i"nt;,',"-' ltl' ,';1,.,,,r,1:tA;'JU0ffifffi.il;:rilifltrrr_ 8
Ovners Signatures Limited Energy/Res
-
$
Limited Energy/Comm --I- S
DATE:
SUBTOTAL OF ABOVE
52 State Surcharge
32 Administrative Fee
TOTAL
40.00
40.00
20.00
36.00
5
RECEIVED
11/- l r)1Y tl()
follow
t
COM M ERCIAL/ I N DUSTRIAL
PERMIT APPLICATION
225 Fitlh Street, Springfield, Oregon 97477
SPRINGFIELEl
t7? 5 /q
4?tzJOB NUMBER
I NSPECTION LINE: 726-3769
OFFICE: 726-3759
a
LOCATION OF PBOPOSED WOR
ASSESSORS MAP:/ttst )LK;
/TAX LOT:o 1{oo
PHONE:
o^
z
STATE:
77v-c 7?/
ZIP:?7 y7 2
OWNER:
ADDRESS:
CITY:
lz /a-
NEW
-
REMODEL ADDITION DEMOLISH OTHEB
rK
VALUE:
DESCRIPTION OF WORK:
ELECTRICAL:
NAME ADDRESS PHONE
coNsr. '7\)))
CONTRACTOR #EXPIRES PHONEADD
>gT ?{+
dn
6
n
?t3o o
ARCHITECT
CONTRACTOR'S NAME ESS
MECHANICAL:
GENERAL:
PLUMBING
PLUMBING
NO.FFF CHARGEtl-Single Fixture '?. o
Relocated Bldg
(new fix. addtl)
Water Service
ft
Sanitary Sewer
ft ?-y 2r
Storm Sewer
ft.
I Backflow Device tf N
ATTENTION:Oregon law rt rquires r
I
'ou to
ir
follow rules adopted by the@
OAR 952-001 -001 0 througl
Oregon
leffire{
rOAR9
Utility
,e+{edtr-
i2.001-
0 190. You may obtain copier of the yh*v*
umberforthe O uri :y Notifi ,Ii;* ra
rorAL pERMl1 Center is 1-800-332-2344)0,/,t?
MECHANICAL
NO FFF EHA RGF
Furnace/burner & vent
< 100,000 BTUs
Furnace/burner & vent
>100,000 BTUs
Floor furnace and vent
Suspended wall or f loor
mounted unit heater
Appliance VentseSfffi'1s'.s.
Statibfa[/E(]p:
coqfEtC llEtrr rr:. ^. . . .
Vent Fa"h it SII\UIET DTTALTEI
duA[iTunprTrr.^ , rr .-.-
f,IBE IF rHE WOBK
Vent System apart
from AC or htg.
lIS PEH t4tT,s NOT
Mechanical exhaust
hood and duct
I'YUUNI D FOR
Permit lssuance $10.00
TOTAL PERMIT
- OFFICE USE -
LAND USE:
ZONING
HANDICAP ACCESS:
FLOOD PLAIN
LIGHTING POWER BUDGET:
WATER HEATER:
OCCY GROUP:
* OF STORIES:
QUAD AREA:
* OF BLDGS:
CONSTB. TYPE:
HEAT SOURCE:
* OF UNITS:
SO. FT.$/SQ. FT,VALUE
TOTAL VALUE OF PROJ
x
X
X
SQ. FTG MAIN
SQ. FTG ACCESS
SQ, FTG OTHER
PLAN CHECK FEE RCPT#DATE BY
f )- 7a
BUILDING PERMIT /7 s1,PLUMBI NG DEMOLITION
5% State
Surcharge / .'(o 5% State
Surcharge
MECHANICAL FENCE
VALUE $
5% State
Surcharge
SIDEWALK
FT.
SUBTOTAL
PERMITS
PAVING CURBCUT
FT.
SYSTEMS
DEVELOPMENT
I C'Qo TOTAL PEBMIT FEES
EXCLUOING ELECTRICAL
t/
^^ll!-- ^L- ^--r^-- ,rr-^- ^
will be
R
-REQUIRED INSPECTIONS
It is the responsibility of the permit holder to see that all lnspectlons are made at the proper time. To request an inspection, call
726-3769 (recorder), state your City designated j ob address, type of inspection requested and when you will be ready
for inspection. Requests received before 7:00 the same working day, requests made after 7:00 a.m. will be made
the following work day.
SITE INSPECTION: To be
made after excavation, but
prior to setup of forms.
H PLUMBING,
be covered until these
UNDERSLAB PLUMBING,
ELECTRICAL &
MECHANICALT To be made
before any work is covered.
FOOTINGS & FOUNDATIONS:
To be made after trenches are
excavated and forms are
erected, all steel in Place, but
prior to placing concrete.
CONCRETE SLAB: To be
made after all inslab building
service equi pment, conduit,
piping, accessories and other
ancillary equipment items are
in place but before any
rete is placed
DERGROUND: Plumbing,
ectrical, gas, sanitarY sewer,
storm sewer, water and
drainage lines. To be made
prior to covering or filling
trenches.
UNDERFLOOR: Plumbing,
electrical, mechanical. To be
made Prior to installation of
floor insulation, decking or
floor sheathing.
POST & BEAM: To be made
prior to installation of floor
insulation, decking or floor
sheathlng.
FLOOR INSULATION &
VAPOR BARRIERST To be
rnade Prior to installation of
decking or floor sheathing.
MASONRY: Steel location,
bond beams grouting or
verticals in accordance with
UBC 2415.
ROOF SHEATHTNG AND
ections have been made
approved.
i nsp
and
RICAL &
ECHANICAL: No work is to
PAVING: After gravel is in
place but prior to placing
asphalt or concrete.
SPECIAL INSPECTTONS: ln accordance
Section 306 of the State Specialty Code
a special inspector shall be employed
by the Owner/ Contractor during
construction of the following work. A
copy of the special testing reports shall
be furnished to the Building Division.
STRUCTURAL CONCRETE: IN
excess of 2500 P.S.l. (306 a.1)
STRUCTURAL WELDS:
Performed on the job. (2722 t)
HIGH STRENGTH BOLTING:
During all bolt installation and
tightening operations. (306
a.6)
SPRAYED ON
FIREPROOFING: U.BC.
Standard$ 43-8.
SPECIAL GBADING,
EXCAVATION AND FILLING:
During earthwork. (306 a.11 &
Chapter 29)
GLU-LAM BEAMS: lnspection
Certificate by an aPProved
agency, furnished to the City's
Building Division before
beams are Placed. (2501 U.B.C.
STDS. 25-1011).
STRUCTURAL MASONRY: (306
a.7)
'ln addition to the inspec-
tions specified, the Building
Official may make or require
other inspections of any
construction work to ensure
compliance with the Building,
City or Development Code.
-F
ATTIC DRAFT STOPS &
CURTAIN WALLS
FIREPLACE: Prior to placing
facing materials and before
I fram)yrg inspection.
I
ING: To be made after
roof, all framing, fire
ocking and bracing are in
place and all pipes, chimneys
and vents are complete and
the rough electrical, plumblng
and mechanical are apProved.
INSULATION & VAPOR
BARRIER: To be made after all
insulation and required vaPor
barriers are in place but
before any lath or gYPSum
board interior wall covering is
applied.
FIRE & SEPARATION WALL:
Located and constructed
according to plans.
/--> CO
N : Prior to installing
coveri ng.
LATH AND'OR GYPSUM
BOARD: To be made after all
lathing and gYPsum board,
interior and exterlor, is in
place but before anY
plastering is aPPlied or before
gypsum board joints and
fasteners are taped and
f inished.
SIDEWALK &. DRIVEWAY:
-
Required for all concrete
paving within street right of
way, to be made after all
excavating comPlete and form
work and sub'base material in
place.
CURB AND APPROACH
APRONS: After forms are
erected but Prior to Placing
concrete.any
FI
By signature, I state and agree, that I have caref ully examined the completed application and do hereby certify th.at all information
herein 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 of Springfield, and the Laws of the State of Oregon pertainlng to the work described herein, and that No oCcUPANCY
will be made of any struciure without permission of the Building Safety Division. I further certify that only contractors and 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 proiect address is readable from the
street, that the permlt card is located at the front of the property, and the approved set of plans will remain on the site at all
Signature Date
times during
VALIDATION:Lsf
8 3. 7/ft].aLRECEIVED BY:
DATE PAIDAMOUNT RECEIVED
RECEIPT *:
PLUMBING
- FINA L ELECTRICAL
FINAL MECHANICAL
FlNAL FIRE DEPARTMENT
SITE PLAN REVIEW BOARD: Must be requested 2 days in advance
of the date you wish inspection. All project conditions such as
landscaping, parking lot stri ping, etc. must be completed before
-.-
FIN
ting this inspection.
BUILDING: Requested after the final plumbing, electrical,
cal and Fire DePart ment inspections are made and
roved. No occuPancY of the premises can be made until a
rtificate of OccuPancY has been issued by the Building Division
and posted on the Premises
ADDITIONAL COMMENTS:
PLANS REVIEWED BY DATE
tf(,f -ocot
construction.
I,I
SPRTNGFIELD
QA
"l i t lollowing proFsf ao arbrn[ilsd hs Up bllofie
225 FIFTE STREET
r ^.ng and doco not reqube epocfic
r,r,DrqvAl.
zon'rE--4-q<.--
7,(&77 D-772GiT69---
BLECTRICAL PERHIT APPLICATION
land rr80
SPRINGFIELD, OREGON 9
INSPECTION REQTIEST:
0FFICE: 7 26_3759 Aurhortzcd
1. LOCATION OF INSTALT.ATTON
l,"lg J. l+,U\ -\,rt .
City Job Number
FEE SCMDULE BELOV
A. Nev Residential-Single or
Multi-Family
qY)Ll1 I
JOB DESCRIPTION
I r *{ i.l) r . \li c(Y\
Service Incl"
SUBTOTAL OF ABOVE
5Z State Surcharge
3Z Administrative Fee
TOTAL
per dvelling uni r.
uded:
s 300
I tems Cos t Sum
1-000 sq
)rRfv,lT s LL -
s XP'BE,FIffi '80tspEach add IS NOTsq. ft or por tion
$ 1s. oothereof
Each Manuf'd Home or
Modular Dvelling
Service or Feeder $ 40.00
Permits are non-transferable and expireif vork is not started vithin 180 daysof issuance oL- if vork is suspended for
180 days.
2. CONTRACTOR INSTALI.ATTON ONLY
0f S 8ttnntrurl.,{nu
B. Services or FeedersInstallation, Alterationsor Relocation:Electrical Contractor
Address P, o.s s0.00
8133:33 r^orco
601 amps to 1000 amps- S130.OOOver 1000 amps/vo1ts
Reconnect 0n1y
C. Temporary Serv alle set
fns talla b.J
0 the
200
20L am
Over 401,r-rtQ
Over 600 " aET?E-
\s1D. Branch Circ
200 amps or less
20L amps to 400 amps -l_
401 amps to 600 ampsCiPhone ,l4l-3to
Superv i sor icense Number b
Expiration Dare t0 -l-q I
Constr Contr. ltumber 58rf,9
Expiration Date q -l-Dn
Signature of S upervising Electrician
Ovners Name
Address
Ci ty Phone - b1s
The installation is being made onproperty r ovn vhich is not intendedfor sa1e, Iease or rent.
Owners Signature:
DATE:
Nev, Alteration or Extension per panel
One Circuit S 35.00Each AdditionalCircuit or vith Serviceor Feeder Permit l0 $ 2.OO LOgO
Miscellaneous (Service/feeder not included)
-Each installation
Pump or irrigation g 40.00Sign/Outline Lighting- S 40.00Limited Energy/Res
-
$ 20.00Limited Energy/Comm S 36.00
E
5 3o. ootl. oo
2, +oRECEIVED B
R t2. +o
0-
OVNER INSTALI^ATION
s