HomeMy WebLinkAboutMiscellaneous Miscellaneous 2009-7-1
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CITY OF SPRINClFIELf>, (Wn30N
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215 .... .n STREET . SPlUNGFlELD, OR 97417 . PH:(S41)726-3753 . FAX: (541)726-3689
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ELECTRICAL MASTER PERMIT..
REGISTRATION APPLICATION
, '.. :1.____. _ __- ..____._____ CU~!()~}N.!ORMATION ,__oj.
I Company: c",{5'C&\'\.4eo - . .. '1 PhoJle:541 - ?-:'-:2f),~~()OO I
I Owner: . (fax: f'5411-:, % - ~Lof) I I
I O_erAddreo5: ~~ \~r()tA-h l~~ S~II'1~:rQ I ZIP: C{l4:7]
I InsoectiOll Address (if different): . , . ... . J, I!
I City: ,/ State: , I ZIP: i
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I REGISTRA TIo.N FEE " .
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~ SI00 1"ltIa1, oD~rlmo~ti"'. r~ (OAR 91&-309-0100(1 Od)) 0 . Roster "~ (no tee ll!OuJred) I
. . . ... ., . 'ROSTER.' it.._ _ -I
. If Ilppli=t is 1m OWOCf or openttit>g """"'lIer, applicllnt 'alii file a roster with the inspcctlngjuri.odlctlon of ,II eleellicl_ curr""~y
employ.d by aJlPUcmt, showlne tholWt1.,electrica.llic"".. number...d l)IJle of eleetlical.license, ""'1,llcleCll1cIll con1l1lCtDr!i wbos..
' wOrk is illcllllleclunder a IIlASlCr pmnit takcD' out by !be OWlIer or apcratin: m:mag.r. Th. roster !'1usl:,be,filedlll The same time os the
pcrtnjt lll>l>1ir:arion. OAR 91 tI.309'()!OO(C6bll . I
I Name of COlltl"lle/or/EJectrlela" (prillt or rype) Licea... No. I
rlA~lflft\ Q'~;(_,3l-{Q'dcr_ Ii ~(J 1\ t 'dt1111
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!WrA ,{ YlP CJ~J)~(/~_AG~EME~aQ3C1Q~_. iOtl I 'om?] ! .
I ~to the terms and conditiOll!l of the MlIsW Permit " ....._ lbavc verificd rh611lt. COIllr/lCIOCS/eleclr1clallS.lImd ehovell'e
eum:ntly Iil:<lOSCd to.\Vort in the State ofOreeClD.. : . .'
E~pira/ioD date
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, Sllll&rvlilDll EleetrlclaD Sll!natllre " - .
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For Office UscOnly
Rec'd:
Approved:
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