HomeMy WebLinkAboutPermit Plumbing 1992-10-20PNINGFIELD
RESID ENTIAL
PERMIT APPLICATION
lnspections: 726-3769
Office: 726-3759
JOB NUMBER
225 Flfth Street
Sprlngfleld, Oregon 97477
)3f s q)e,Ll
LOCATION OF PROPOSED WORK
ASSESSOBS MAP:\-l oa3tr aa TAX LOT:antao
LOT .-- BLOCK SUBDIVISION:
PHONE:
1L
OQ q)q) eZtP:STATE:
1at 8LL1
CITY
OWNEFI:
-
ADDRESS:
DESCRTBE woRK: -MK-IS?-
NEW _- BEMODEL ADDITION DEMOLISH OTHER
\De.tsr.-, t oI
EXPIRES PHONEADDIIESS
Qrrrv-z ( -
ELECTRICAL: -- -=,--
MECHANICAL:
PLUMBING
CONST.
CONTRACTOR #CONTRACTOFI'S NAME
GENERAL: ---
RANGE:
# OF BDRMS
* OF STORIES: - -
- OFFTCE USE -
ZONING CODE:
FLOOD PLAIN
OCCY GROUP: --_.=--
WATER HEATER:
SECONDARY HEAT:
SOUARE FOOTAGE:
CONSTR. TYPE:
HEAT SOURCE:
LAND USE:
# OF UNITS
OUAD AREA:
# OF BLDGS
To request an inspection, you must call 726-3769. Thls ls a24hour recordlng. All lnspectlons requested before 7:00 a.m. wlll be
made the same worklng day, lnspectlons rcquested after 7:00 a.m. wlll be made the followlng work day.
REOUIRED TNSPECTIONS
[--l remporarY Electrlc
Site lnspecllon - To be macje
af ter excavation, but Prlor to
setting forms.
Underslab Plumbing / Electrlcal /
Mechanical - Prlor lo cover.
Footlng - After trenches are
excavated.
Masonry - Steel location, bond
beams, groutlng.
Foundallon - After forms are
erected but prior to concrete
placement.
Underground Plumbing - Prlor
to filllng trench.
Underlloor Plumblng / Mechanlcal
- Prior to lnsulatlon or decklng.
Post and Beam - Prlor to floor
insulatlon or decklng.
Rough Mechanlcal - Prlor to
cover.
n Rough Electrlcal - Prlor to
cover.
Electrlcal Servlce - Must be
approved to obtain permanent
electrlcal power.
Fireplace - Prlor to faclng
materlals and framlng lnsP.
Framlng - Prior to cover,
Wall/Celllng lnsulalion - Prlor to
cover.
Drywall - Prlor to taPing
Wood Stove - After lnstallatlon
lnserl - After flrePlace aPProval
and lnstallatlon of unlt.
Curbcut & Approach - After
forms are erected but Prior to
placement of concrete.
[--] Fence - When completed,
Street Trees - When all requlred
trees are planted.
Flnal Plumblng - When all
plumblng work ls complete.
Flnal Eleclrlcal - When all
electrlcal work is complete.
Flnal Mechanlcal - When all
mechanlcal work ls complete.
Flnal Bulldlng - When all
requlred lnspectlons have been
approved and building is
completed.
Other
MOBILE HOME INSPECTIONS
Blocklng and Set.Up - When all
blocklng ls complete.
Plumblng Connectlons - When
home has been connected to
water and sewer.
Electrlcal Connectlon - When
blocklng, set-up, and plumblng
lnspectlons have been approved
and the home ls connected to
the servlco panel,
rJ
r
Floor lnsulatlon - Prior to
decklng. - ,ls1.)'
Sanitary Sewer - Prior to filling
trench.
Slorm Sewer - Prlor to fllllng
trench.t:io ,
Waler Llne - Prlor to fllllng
trench,E
Rough Plumblng - Prior to
cover.ventlng have been Installed
qltl1 h
r
E
E
r
and
Ef_l Sldewalk & DrlvewaY - AfterlJ excavatlon ls comPlete, forms
and sub-base materlal ln Place.
and
P.L,HSE GAR ACC
N
S
E
-- THE PFloPosED woFIK lN THE
, TISTORICAL DISTRICT, OR ON
THE HISTORICAL REGISTER? -_.----
lf yes, this appllcatlon must be signed
and approved bY the Hlstorlcal
Coordinator prlor to permit issuance.
APPROVED:
Lot
Lot
f aces
sq. ftg.
Lot
Lot coverage
TopograPhY
Total height -
Panhandle
--
Cul-de'sac
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on tlre express condition that the said
consiruction shall, in all respects, conform to the Ordinance
adoptecl by the City of Springfield, including the
Development Cocie, regr.rlatir-rg the construction ancl use of
builrJings, ilrrrl nt;ry llc susllencled or revoked at alry tlrll{)
upon violati<.rn of any provisiot'ts of sald ordinatrccs'
Plan Clteck Fce:
DatcPlans Revit:wccl t3Y
Date Paid
Recei Pt Nutnbcr:
Received BY:
BUILDING PERMIT
VALUE
(A)
SO. FT. X $/SO. FT.ITEM
Main
Garage
Carport
Total Value
Building P€rmit Fee
State Surcharge
Total Fee
Systems Developnlent Charge is due on all undeveloped
properties within the City limits which are being improved'SYSTEMS DEVELOPMENT CHARGE (SDC)
(B)
ADDITIONAL COMMENTS
ITEM
Fixtures
Residential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
PLUMBING PERMIT
FEE
No
nr. {fr0
3O,oo
4 0(l
(c)
40 .oo<o
40 .oa
aq o0-
FT. I
FT. I
Plumbing Permit
State Surcharge
Total Charge
Wood Stove/ lnsert/ Flreplace Unlt
Dryer Vent
MECHANICAL PERMIT
(D)
N0
Mechanical Permlt
lssuance
State Surcharge
Total Permit
Furnace
Exhaust Hood
Vent Fan
By signature, I state and agree, that I have caref ully examined
the completed application and do hereby certify that all
lnformation hereon is true and correct, and I further certify
that any and all work performed shall be done in accordance
wlth the Ordinances of the City of Springfield, and the Laws
of the State of Oregon pertalnlng to the work described
herein, and that NO OCCUPANCY will be made of any
structure without permission of the Building Safety Division'
I further certify that only contractors and employees who
are ln compliance with ORS 701.055 wlll be used on this
prolect.
I further agree to erlsure that all required inspections are
requested at the proper time' that each address is readable
from the street, that the permlt card ls located at the front
of the property, arrd the approved set of plans will renrain
tr:_-
U
Sign
Date
on the slte at all ti construction
MISCELLANEOUS PERMITS
Moblle Home
State lssuance
State Surcharge
Sidewalk
-
ft
Curbcut
-
ft
Demolltion
State Surcharge
Total Miscellaneous Permits (E)
lol I
DATE PAID
--
I)AT C1-}-
VALIDATION
RECEIPT NUMAER --- AS 3\4
o6
AMOUNT RECEIVED $ tYod
RECEIVED BY-- -
TOTAL AMOUNT DUE (excludlng electrlcal)
(A, B, C, D, and E Combined)
9g*-ao_
5llr-- 9c' &-
'-\r\---
2
Permit No:4 tt 1b
Address:]3) S, 4 )n&st-^
lssued ov: QB
OR OFFICE USE ON
STATEMENT:
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
Note: Oregon Law, ORS 701.055(4) , requires residential construction permit
applicants who are not registered with the Construction Contractors Board to
sign the following statement before the building permit can be issued. This state-
ment is required for residential building, electrical, mechanical, and plumbing
permits. Licensed Architect and Engineer applicants, exempt from registration
under ORS 701.010(7), need not submit this statement. This statement will be
filed with the permit.
Fill in the applicable blanks, and initial boxes 1 and 2, and either box 3A or 38:
I own, reside in, or will reside in the completed structure.
I understand that I must register as a construction contractor if the structure is sold
or offered for sale before or upon completion.
3.A My general contractor is ,
Contractor registration nu
I will instruct my general contractor that all subcontractors who work on the struc-
ture must be registered with the Construction Contractors Board.
OR
3. B. axl I will be my own general contractor.
lf I hire subcontractors, I will hire only subcontractors registered with the Construc-
tion Contractors Board. lf I change my mind and do hire a general contractor, I will
contract with a contractor who is registered with the Construction Contractors Board
and I will immediately notify the office issuing this building permit of the name of
the contractor.
I hereby certify that the above information is correct and that I have read and understand
the lnlormation Notice to Property Owners about Construction Responsibilities on the
reverse side of this form.
lDl:o\r=
ignature o cant Date
CON STR UCTION CONTRACTORS BOARD
0244J 8191
WHITE COPY TO ISSUING AGENCY PERMTT FILE
PINK COPY TO APPLICANT
Date:'olcdq-,
=:;NERSABOUT CONSTRUCTION RESPONSIBILITIES
NOTE: This lnformation Notice to Property Owners About Construction Responsibilities
was developed by the Construction Contractors Board in accordance with ORS 701O55(O,
passed by the 1989 Oregon Legislature. ' *1i- .
lf you are acting as your own contractor to construct a new home or make a substantial imprOlement to an
existing structure, you can prevent many problems by being aware of the following responsibilities and areas
of concern
EMPLOYER RESPONSIBILITIES:
lf you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting
in the construction or improvement of a residential structure, you will, in most instances, be ruled to be an
"employer" and the people you l'tire will be "employees". As the employer, you must comply with the following:
Oregon's Withholding Tax Law: As an employer, you must withhold income taxes from employee wages at
uwillbeliableforthetaxpaymentsevenifyoudon]-tactuallywithholdthe
tax from your ilmployees. For more information, call the Oregon Department of Revenue at 378-3390.
Unemployrnent lnsurance Tax: As an employer, you are required to pay a tax for unemployment insurance
mployees,Formoreinformation,calltheoregonEmployment,DivisionDHR
a|378-3224.
,Y.qtgfs' ggrpgqation lnsurancg As an employer, you are subject to the Oregon Workers' Compensation
r-ar,v'affiompensationinsuranceforyouremployees.lfyoufailtoobtainworkerS'
compensation insurance, you may be subject to penalties and will be liable for all. claim costs if one of your
employees is injured on the job. For more information, call the Workers' Compensation Division DIF at S&74U.
U.S. lnternal Revenue Service: As an employer, you must withhold federal income tax from employees'wages.
even if you didn't actually withhold the tax. For more information, callYou will be liable for the tax payment
the lnlernal Bevenue Service at 22't-3960.
OTHER RESPONSIBILITIES AND AREAS OF CONCERN:
-iqg_agryllglge: As the permit holder for this project, you are responsible for resolving any failure to meet
ilode requirements that may be brought to your attention through inspections.
lgptlity and froperty lnsurance: Contact your insurance agent to see if you have adequate insurance
coverage for acciOents and omissions such as falling tools, paint overspray, water damage from pipe punc-
tures, fire, or work that must be re-done.
Time to Supervise Employees: Make sure you have sufficient time to supervise your employees.
lvlake sure you have the expertise to act as your own general contractor, to coordinate the work
of rough-in and finish trades, and to notify building officials at the appropriate times so they can perform
the required inspections.
lf you have additional questions, write to Construction Contractors Board
700 Summer St. NE, Suite 300
Salem, OR 97310-0151
Phone 503-378-4621
o244J 10t24189
l/00D STOVE/INSERT INSPEC.I
CITY OF SPRINGFIELD
BUITDING SATETY DIVISION
225 Fifth StreetSpringfield, 0regon 97471
Job Locat ionz Z3 Z {oaff
Assessors H.p #,
0vner:
-ATION
0ffi ce:
INSPECTION LINE:
726-3759
726-3769
zdtf AFR\,tr
Tax Lot *:
5,k
Ci ty:
\Value of llood Stove
(please circle
Con t rac tor:
Preliminary Inspection is 915IJood Stove/Pellet/Insert perm
Type of Inspection Requested:
tBr
Address , lC a/ z Phone *r 9 ?/-s6{1
OR zip .a 7 177
.00 (prior to installation o f insertit is $15.00 +s10.00 r ce+state surcharge.
Phone *:7qt-86{/
State:oQ.zip:
Expires:
3
e
FOR OFFICE USE
a
S ta te:
Insert:
appli ance
5
Address, PO GcX la lz
Ci ty:Prt D
By signing this permit/application, r agree to call for an inspection(s) as required(726-3769)' r state that aII informati5n on this application/permit is correct andtha-t r vas provided vith the uood Stove safety infoimation for vood burningapplianees and preliminary inspection standaris. r further state that the appliancer am installing meets smoke emission standards as set by the oregon Department ofEnvironmental Quarity or the Federal Environmental Protlction Agency "na r agree toprovide the testing approval number to the inspector at the time of inspecti6n. Ialso understand that if I am requesting a preliminary inspection, the vaII coveringmay be required to be removed.
Construction Contractors Registration #:
/
gna tur
let St
REQUIRED INSPECTI0N(S) : UOODSTOVE /PELLET /INSERT PRELIMINARY
Job #:3 \,q3Date of Application:
TotaI Amount Collected:
Receipt #:=
Checked for Delinquencies:
I ed By:
Checked for Historical Status:
BoX
N)
SP]lINGFTELE'
RESIDE..,'(TIAL
PERirriT APPLICATION
lnspections: 726-3769
Office: 726-3759 h,
JOB NUMBER
225 Fifth Street
Springfield, Oregon 97 477
LOCATION OF PROPOSED WORK:7-9- q,- 42-r$
TAX LOT:c)2 r oo
SUBDIVISION Fft-ori-p {-
ASSESSORS MAP:
LOT:Nofrlr lA oe LoT 13 BLOCK
PHONE:
zlP:q1+nSTATE:
A
c)DCITY:Fu96-9rs.E
P. c>. ffclx \\-?z zADDRESS:
OWNER
NEW
-
REMODELY ADDITION DEMOLISH OTHER
\{o*.>*t+aDESCRIBE WORK:P-ar.crrrC-tgt OG E*\<T r*r.- ?
ADDBESS EXPIRES PHONERACTO
I
\
CONTFIACTOR'S NAME
GENERAL
ELECTRICAL:
PLUMBING
MECHANICAL:
CONST.
CONTR
Ol., I r-r F-f2
^-3
2-
El- ,
_ OFFICE USE _
RANGE:WATER HEATER:
* OF BDRMS:V.N
Et/J.
QUAD AREA:
* OF BLDGS:
SECONDARY HEAT
SQUARE FOOTAGE:
CONSTR. TYPE
HEAT SOURCE:
LAND USE:
# OF UNITS
OCCY GROUP:
* OF STORIES:
FLOOD PLAIN:
ZONING CODE
To request an inspection, you must call 726-3769. This is a 24 hour recording. All inspections requested before 7:OO a.m. will be
made the same working day, inspections requested after 7:00 a.m. will be made the following work day.
REQUIRED INSPECTIONS
Temporary Electric lVl Rouqh Mechanical - Prior toz\l cove-r.
YJ Rough Electrical - Prior to
-
cover.
ffi Final Plumbingla plumbing work - When all
is complete.
Site lnspection - To be made
after excavation, but prior to
setting forms.
K Final Electrical - When all
electrical work is complete.
E
X
Undersl ectrical/Electrical Service - Must be
approved to obtain permanent
electrical power.
x.Final Mechanical - When all
mechanical work is complete.Mechanic or to cover.
Footing - After trenches are
excavated.Fireplace - Prior to facing
materials and framing lnsp.
x Final Building - When all
required inspections have been
approved and building is
completed.Masonry - Steel location, bond
beams, grouting.xx
x.
Framing - Prior to cover.E Foundation - After forms are
erected but prior to concrete
placement.
Other
Wall/Ceiling lnsulation - Prior to
COVET,
Underground Plumbing - Prior
to filling trench.Drywall - Prior to taping
MOBILE HOME INSPESTIONS
Underlloor Plumbing/ Mechanical
- Prior to insulation or decking.Wood Stove - After installation
Posl and Beam - Prior to floor
insulation or decking.lnsert - After fireplace approval
and installation of unit.
Blocking and Set.Up - When all
blocking is complete.
x,Floor lns Prior to Plumbing Connections - When
home has been connected to
water and sewer.
decki Curbcut & Approach - After
forms are erected but prior to
placement of concrete.Sanitary Sewer - Prior to filling
trench,Electrical Connection - When
blocking, set-up, and plumbing
inspections have been approved
and the home is connected to
the service panel.
K Storm Sewer - Prior to filling
trench.
Sidewalk & Driveway - After
excavation is complete, forms
and sub-base material in place.
Water Line - Prior to filling
trench.l--l Fence - When completed
Rough Plumbing - Prior to
cover.
Street Trees - When all required
tie?s are planted.
Final - After all required
inspections are approved and
porches, skirting, decks, and
venting have been installed.
mbi
E
l?- o.2-- 32-- \ -3
ffitcr\sYr- G . Husc-i;-r I
__Lx_
2
E
rl
E
fl
I r
Lot faces
Lot sq. ftg.
Lot coverage
Topography
Total height
Lot Type
-
lnterior
-
Corner
-
Panhandle
Cul-de-sac
Setbacks
P.L.HSE GAR ACC
N
S
E
J THE PROPOSED WOFIK iS-rNE
HISTORICAL DISTRICT, OR ON\.
THE HISTORICAL REGISTER?
-
lf yes, this application must be signed
and approved by the H istorical
Coordinator prior to permit issuance.
APPROVED
BUILDING PERMIT
ITEM SQ. FT.X $/SQ, FT.VALUE
Main
Garage
Carport
Total Value
Building Permit Fee
State Surcharge
Total Fee
20,/nn
/T5"
703
/42,s3(A)
BUILDING VALUE, PLAN CHECK
AND BUILDING PERMIT
This permit is granted on the express condition that the said
construction shall, in all respects, conform to the Ordinance
adopted by the City of Springfield, including the
Development Code, regulating the construction and use of
buildings, and may be suspended or revoked at any time
upon violation of any provisions of said ordinances
7/., s 7/3 3
Plan Check Fee
3-zo -,o
Date Paid
Fleceipt Numbe u/6
Rec
t2'/7-7/
Plans ewed By Date
SYSTEMS DEVELOPMENT CHARGE (SDC)
YLE
(B)# 4n'3
Systems Development Charge is due on all undeveloped
properties within the City limits which are being improved.
PLUMBING PERMIT
ITEM
Fixtures
Residential Bath(s)
Sanitary Sewer
Water
Storm Sewer
Mobile Home
uc FEEja?
N0
FT.
FT.
FT,
Plumbing Permit
State Surcharge
Total Charge
_b24
3,oo
(c)63?o
ADDITIONAL COMMENTS
MECHANICAL PERMIT
Fu rnace
Exhaust Hood l/-
Vent Fan N0
Wood Stove/ lnsert/ Fireplace Unit
Dryer Vent y'-
Mechanical Permit rrlrt),/5.oo
lssuance
State Surcharge
Total Permit
/O'tu
,7<
(D)25.7s
By signature, I state and agree, that I have caref ully examined
the completed application and do hereby certify that all
information hereon is true and correct, and I f urther 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 pertaining to the work described
herein, and that NO OCCUPANCY will be made of any
structure without permission of the Building Safety Division.
I further certify that only contractors and employees who
are in compliance with ORS 70.1.055 will be used on this
project.
I further agree to ensure that all required inspections are
requested at the proper time, that each address is readable
from the street, that the permit card is located at the front
of the property, and the approved set of plans will remain
on
7G,n C
Date \z-T)-Q.,r\\
ton
MISCELLANEOUS PERMITS
Mobile Home
State lssuance
State Surcharge
Sidewalk
-
ft
Curbcut
-
ft
Demolition
State Surcharge
P/,.A) Eett - t lq f"
Total Miscellaneous Permits (E)
VALIDATION
RECEIPT NUMBER 3 72/
DArE PAID ^ '2 >2 /
AMOUNT RECEIVED
FIECEIVED BY
TOTAL AMOUNT DUE (excluding electrical)
(A, B, c, D, and E Combined)aB6
fW 't- L S7';* t?E ltt7t)!
JOB NO.4tt -G
CITY OT SPNTNGFIELD SYSTEMS DEVELOPMENT CHARGE
WORKSHEET
(coMt'tERcIAL & RESIDENTIAL)
NAME 0R C0MPANY: Mrcr-lAev 6 . 1)o*+e'(
L0CATI0N: Z4z , .+?t? :r \1-oZ -bz -*- 0z\60
DEVELOPMENT TYPE:LP 7 ApprT tol-\
BUILDING SIZE:LOT SIZ F sQ. Ft.
1. STORM DRAINAGE
IMPERVIOUS SQ. FT.1ba x 50.186 PER sQ. FT. S lTl+2
(See Reverse For Runoff Coefficients If Actual Imperv. Area Is Unknown)
2. SANITARY SEWER-CITY
NO. OF PFU'S $ U-1o2
(See Reverse To Determine Total PFU'S)
3. TRANSPORTATION
NO OF UNITS X TRIP RATE X COST PER TRIP
1
x $388.61
x $388.61
x _ x $388.61
(See Attachment C To Determjne Trip Rates)
SUBToTAL (ADD ITEMS 1,2, & 3)
ADMINISTRATIVE FFF!
BASE CIIARCE (SU3TTTAL AB0VE) X .05
TOTAL-CITY SDC s+a!
SANITARY SElllER-MI^JMC
NO. OF PFU'S S13.25 PtR PFU + 510 I'lhll,lc ADI'IlN. FiE S
x
X
$-
$
s
$ *ol?
n
5
(Use PFU Total From Item 2 Above)
MI,IMC CREDIT IF APPLICABLE (SEE REVERSE)
)^,)-
Ki p Burd'i ck
SDC Coordinator
sLo
$
TOTAL-MI^'MC SDC 5-+IL q ,4\
TOTAL SDC s 4t164
X 538.55 PER PFU
L
0
FIXTURE UNIT CALCUL --lON TABLE: Number of New Fixture Unit Equivalent = Fixture Units (NOTE
For remodels, calculale only the NEI'additional fixtures)
NUMBER OF UNIT FIXTURE
FIXTURE TYPE NEW FIXTURES EOUIVALENT UNITS
Bathtub.......Z
Drinking Fountain.....
Floor Drain.
I nterceptors For Grease/Oil/Solids/Etc.................
I nterceptors For Sand/Auto Wash/Etc..................
Laundry Tub/Clotheswasher
Clotheswasher - 3 Or More...........
Mobile Home Park Trap (1 Per Trailer)........
Receptor For BefrigeratorflVater Station/Etc........
Receptor For Commercial Sink/Dishwasher/Etc..
Shower, Single Statl...
Shower, Gang...........
Sink, Bar, Commercia1...................
Urinal, StallflVall....
Wash Basin/Lavatory, Single.......-.
Water Closet, Public lnstallation..
Water Closet, Private........
Miscellaneous:
TOTAL FIXTURE UNITS
CBEDIT CALCULATION TABLE: Based on assessed value. lf improvements occurred after annexation date in table,
calculate credits se
Credit for Parcel or Land Only lf Applicable X S
-1natax
RsesseJf"tue;
lmprovement (if after annexation date)X$
(Rate X Assessed Value)
CREDIT TOTAL _ S
2
1
2
3
b
2
o
6
1
3
2
1
2
2
1
6
4
/Head
-7
Year
Annexed
Rate per $1,000
Assessed Value
Year
Annexed
Rate per S1,000
Assessed Value
1979 or before
1980
1 981
1982
1983
1 984
$2.66
2.U
2.53
2.41
2.19
2.04
1985
1 986
1 987
1 988
1 989
1 990
$1.69
1.35
't.15
0.92
0.59
0.23
RUNOFF COEFFICIENTS FOR STOBM DBAINAGE
Residential..
Commercial
lndustrial.....
Governmental.
0.4
0.9
0.45
0.5
IMPERVIOUS AREA = TOTAL LOT SIZE X RUNOFF COEFFICIENT
C'TY OF OREGO'U
225 FIFTB SInBEf,
SPRTNGFTBIJ, oREGoN 97477
INSPECTI0N REQIEST. 726-3769
oPFICE: 726-3759
1. LOCATION OF INSTALI,ATIONild
I,EGAL DESCRIPTION
ta22- __32- 3 3 b?-1OO
JOB DESCRIPTION
Permits are non-transferable and expireif vork is not started vithin 180 daysof issuance or if vork is suspended for
180 days.
2. COT{I"ACf,OR INSTALI,ATION ONLY
Electrical Contractor
Address
city- Phone
Supervisor License Number
Expiration Date
Constr Contr. Number
Expiration Date
Signature of Supervlsing Blectrician
Owners Name
Address P,o AN lla 2z-
OVNER INSTALLATION
The installation is being made on
property I ovn which is not intended
for sale, lease or rent.
Ovners ignature:
DATE:
st'ilrNGFrEL(}
BLECTRICAL PBRHIT APPLICATION
City Job Number
3. COHPI,,ETE FBE SCTIEDULE BELOV
Nev Residential-Single or
MuIti-FamiIy per dvelling unit.
Service fncluded:
Items Cost
L000 sq.ft. or less
Each additional 500
sq. ft or portion
thereo f
Each Manuf'd Home or
Modular Dwelling
Service or Feeder
$ 8s.00
$ 1s.00
$ 40.00
B. Services or Feeders
Installation, Alterations or
Reloca t ion:
A
200 amps
201 amps
401 amps
601 amps
Iess
600 amps
1000 amps
Sum
.00
.oo
.00rrgr "f,ffi
or
to
to
to
$ s0.00
$ 60.00
$100.00
$130.00
$300.00
$ 40.00
Over 1000 amps/volts
Reconneet Only
C. T'emporary Services or FeedersInstallation, Alteration or Relocation
200 amps or less $
201 amps to 400 amps
-
$
over 401 to 600 amps _ $
0ver 600 amps or 1000 volts se
40
55
80
r€
ciw &qaE "74((,"e lg4 -4s€/
D. Branch Circuits
E
Nev, Alteration or Extension Per Pane}
One Circuit /.,' S 35.00 ffi"Each Addi tional
Circuit or vith Service
or Feeder Permi t /5 S 2. O0 jDPo
Hiscellaneous (Service/feeder not included)
-Each installation
Pump or irrigation $
Sign/OutIine Lighting- $
Limited Energy/Res $Limited Energy/Comm $
05,oo
40.00
40.00
20.00
36.00
5. STETOTAL OP ABOVE
5Z State Surcharge
TOTAL
BRECEIVED
x
.2,-9
. /^9^