HomeMy WebLinkAboutPermit Electrical 2009-6-12
Electrical Permit Application
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Ii Permit no.: CY' --- ~ 5? I
Date ~//d-/O 9' ~ (~/4/oi)
This permit is issned under OAR 918-309-0000, Permits are nontransferable. Permits expire if work is not started within 180
days of issnance or if work is snspended for 180 days. :: ' '
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Residential, per unit, service included: I .
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1,000 sq. ft. or less (4) "
I Each additional 500 sq. ft. or portion;
thereof . "
I Limited energy (2)
I' Each manufactured home' or modular $
dwelling servi.ce or feeder (2) $ 63,00
I Services or feeders: instq/fation, alteration, re/~cation
I 200 amps or less (2) $ 81,00 $
I 20 I to 400 amps (2) $ 95,00 $
I 40 I to 600 amps (2) $158,00 $
I 60 I to 1,000 amps (2) $205,00 $
lOver 1,000 amps or volt~i(2) $469,00 $
I Reconnect only (2) !l $ 63,00 $
I Temporary services or ~eeders: installation, alteration, relocation
I 200 amps or less (2) $ 63.00 $
I 201 to 400 amps (2) $ 87,00 $
I 401 to 600 amps (2) $126,00 $
lOver 600 amps or I ,000 ~olts, see services or feeders section above
I Branch circuits: new, afieration, extensio'n per panel
I I a. Fee for branchcircuits::with purchase of a service or feeder fee:
I I Each branch circuit I I $ 6,00 I $ I
I I b. Fee for branch circuits;;without purchase of a service or feeder fee: 1
I I First branch circuit (2) I $ 55.00 $ .b5~
1 I Each additional branch'circuit q $ 6.00 $M.~
I I Miscellaneous fees: serv!.ce or feeder, ':lot included I
.1 I .Each pump or irrigation sircle (2) $ 63.00 $ 1
I I Each sign or outline lighting (2) $ 63,00 $ I
I I Signal circuit or alimited':..energy panel, $ I
alteration, or extension (2) , $ 63.00
I Each additional inspection: (I) . $58,01 $ I
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(A) Enter subtotal of above fees
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,...{A (Minimum Permit Fee $58.00)
\\9'V.' ".-"/C,;:I:'.(!?).Enter 12%snrcharge'(.12 x [A]),
\9' -, A\~ 'I (cj Technology Fee (5%?f[A])
~ 't>'\ I TOTAL fees and snrc~arges (A throngh C):
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225 Fifth Street. Springfield, OR 97477+PH(541)726-375H FAX(541)726-3689
I :'~i; :!I'~,' ("{L!OCAl::'G0VE_Rf\lMEN'Tf;~F1RR0YAlfr\',;:1~lEii!l'iir);)j:
I Zoning approval verified? 0 Yes 0 No
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I !1KJ Residential I "0 Government I 0 Commercial
1~\_1J~OBiSlmEj~INF.QRM.j).if:ION11~ND~I'!O.c'Nlji0Nr..~~~~!:
Job site address: \\o}) b^lu, A,ll
City: Str~l\)~_l\l I State: ep." I ZIP: 0,'1--\'1-1-
I Refere~ce: '\ fl03'J:\ ffl.. I Taxlot, D\ ~
. .....,;,;'..-DESCRIRTI0N;,QF~,WORI{':11t'!:M~j;j;"~~,~1'I'~;1,;~;
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i ,,:RRO:i>,ERTY~'OWIIIER.>,1
I Name: ,'),^",^~f'\ .\..ow.L I
I Address: i\.sS- L~,,1t,/\ (':l.;L I
I City ~r)^l ~ I \ ^ I State: bit. I ZIP ~ '1'-\1-1-
I Phone5'-I\-4lC;"- ,oll-:r I Fax:S-~\\ -J+\- 'i?\S
I E-mail: .~i..VJ\.-..iO~.\t\lJ. @ J~u, UJ..."",
This instalration is being made on residential or farm property
owned by me or a member of my immediate family, This
property is not intended for sale, exchange, lease, or rent. OAR
479.540(1) an;~479,~60(l)
slgnature:Gl'-~ ~~
I .'. ,\';;;COIII'TRActQRtlNSTAIUi,il.TION', . ,','
I Business name; fu"N. ow"-tA
I Address: (;.,\I'^o( ...(" ,,\,.'^
I City: I
I Phone:
I E-mail:
I CCB license no.: I BCD license no,:
I Signing supervisor's license no.: ;,I".~
I Print name of signing supervisor: ,--"1C--V"\~~'" \sfv-L..
I Signature of signing supervisor: ("17' '
State:
I Fax:
I ZIP:
440-2584-) (9/08/COM)
$134,00
$
$ 25.00
$
$ 32,00
$
$ /O~~ 0l.J
$ 5fS'S
$ ;3.oe'
$ /;)7- 53
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Construction' Contractors Board
700 Summer St NE'Suite 300
PO Box 14140
Salem OR 97309-5052
Phone: 503-378-4621
Web Address: www.ccb.state.or.us
Permit #: C c? - &55'
. Address/~ S L-Llt~'
Is4::':~ . ~; Date:~jd,1) 7
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Statement: Information Notice t roperty Owners
About Construction Responsibilities,
Note: Oregon Law, ORS 701,05 5(4) requires residential construction permit applicants who are not
licensed'with the Construction Contractors Board to sign the following statement before a building
permit can -be issuf!d. This statement is requited for residential building, eleCtrical, mechanical and.
plumbing permiis. Licensed architect and engineerappliccmts, exempt from licensing under
ORS 701.010(7), need not submit this statement. This statement will be filed with the permit.
Fi/in the app>vp,;a~e ~~ankS ~.d init~al ~oxe~ I and 2, and either box 3A or 3B:
El .I. I own; resldem, or will reSIde ill the completed structure., '.
o 2. I understand that I must become licensed as.a C(lDstruction contractor if the structure.issold or
offered ~or sale before or on completion.
':1.
o 3A. My general contractor is
(Name)
(CCB #).
"
1, will instruct my general contractor tI1at all subc~ntractors who. ~ork on t~e structure must be
'licensed with the Construction Contractors Board. "
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OR
3B. ~ will be my own general contractor.
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If I hire subcontractors, I will hire only subcontractors licensed with the Cpnstruction Contractors
Board. IfI change my mind and hire a general contractor, I will contract with a cuntractor whq is,
licensed with the CCB and 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 do understand the Information
Notice to OJ;operty Owners about Construction Responsibilities on the reverse side of this form.
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/ I1Signature of permit applicant) . (Date)
. . . , " [/ ~ite copy to issuing agency permit file, pink copy t(i applicant.)
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Property- owner.doc 06-01-04
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Acting as YOQJr\O:wnGellJleJra~ Contractor?'
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.INFORMATION:NOTICE'TO,PROPERTY OWNERS '..; ''''\'
~~OU!_~PN.~~~y,cT!q"'RESPONSIBILlTIES' e,. ;
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NOTE: This Information Notice to Property Owners about Construction Respon~ibi/ities ~as developed by the
Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature.
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If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing
structure, you can prevent many' probierl1sby being aware oIthe following resp,onsibilities and' concerns.
Employer Responsibilities
'. ~ . ::t . -', '. _. \~~, .,' \' ,'.! _ .. .' . .' ,.
you,will, in most instances, 1:>e ru,le.d.tobe an.:'.emp\oyer",an~ the c?ntr!lctors you_ton\1'a~twitj1 wil} be "employees" iJ
you useconu;actors notlic:n~e~ \Vith tJ,le. ~oi1st:r:'c~on Go~tr~~,to;s Bo"!,d t() d? ,labor in C()n,s~c~ng?r to as~.i~~ in the
constructlOn,or Improvement of a,resldenttal structure, As the employer, you must comply WIth the followlDg:
, .,~. . - .' . "'. ...... , ,- . " ".' - ~'" .' . . . ,
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Oregon's Withholding Tax Law: As'im employer; you must withhold'iii.co~e taxes !rom einpioyee wages at the lime
employees are paid. You will bS liable fO,r the tax. payment~ even. if you don't actually wit~hold the tax from your
employees. 'For more informatian,'call tlie'Department of Revenue at 503-378-4988:) . , ." ",:: ~:'..~
Unemployment Insurance Tax: As an employer, You'are~required td pay a tax-for UIlemploymentinsurance purposes':
on the wages of all employees. For more information, call the Oregon Employment Deparltp.ent at 503-947-1488,
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The Oregon Business Identification Number (BIN) is a com1;>ined nUl]1berJ f9r 90th Qregol1:Witliliolding ~nd
Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or www.dor,state.oLus/formsnav.htmll 'for the
appropriate forms.
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Workers' Compensation Insurance: As an employer, y~u are subject to the Oregon Worke~s' C~'''t'.:...sation Law,
and must_ ~!Jt!ij~ w~r~ers: 20mpen.~a!ion,.i...n~l1!ance Jor ~o,ur employe~s. If you f!lil to ~bta.in:wor1<ers' ,compensation
insurimc'e, you 'could be' subject to penalties and'be'liable 'fof all'c1aimc6sts if otie of your employees is'injl!red on the
job. For'more information, call the'Workers' Compensation bivisionat the'Departinent'o{ConsUlner and Business
Services at 503-947-7815. !
U.S. Internal Revenue Service: .As an employer~ you mU6i/~ithhold :fedefahn'conie .tax '!Toin leiiiployees' wages:; (
You will be liable for the tax payment even if you didn'l actually \vithhold the tax. For a FederalEIN number, call the
IRSat.1-800"829-4933 or. visit their web ,site atwww.irs,!!ov. .'" '. ;'r.. ,,;;:.e,:..,,~~. ..
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, . " _ Othet ~esp~nsit>UJtie~;alJ]d1 Are_as of Concerns.
Code Compliance: As the permit holder for this project, you are responsible for resolving any failure to meet code
requirements that may be broyght to your !1ttention through inspections.
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Liability and Propert~ Damage:.i:nsurance:'Coittact"yourinsunmce'agent.to see 'if you have adequate-insurance
coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe punctures, fire or
work that must be redone. \ '
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Time: Make sure you have sufficient time to superVise your employee~:, ,,'J, '; ,.'
Expertise: Make sure ydu' hav~ the skills t~ act ~s' ~our' o~ g~neral coii1ract~r, to -~oordjmit\: the work of rough-in
and finish trades, and to notify building officials as the appropriate times so they.can perform the required inspections.
If you have additional questions call the Construction Contractors Board (503-378-4621) or write the agency at PO
Box 14140, Salem, OR 97309-5052.
Property _ owner.doc 06-01-04
225 Fifth"Street
r
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2009-00653
COM2009-00653
Payments:
Type of Payment
Check
cRcccintl
RECEIPT #:
Description
+ 12% State Surcharge
+ 5% Technology Fee
Paid By
EILEEN LOWE
~f.~'R1NQF111LO '.".." .....
iii: - ..
City of Springfield Official Receipt
Development Services Department
Public Works Department
1200900000000000673
Date: 06/12/2009
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
njm 1008 In Person
Payment Total:
Page I of 1
8:20:34AM
Amount Due'
110,03
45.85
$155.88
Amount Paid
$155.88
$155.88
6112/2009