HomeMy WebLinkAboutPermit Electrical 2009-8-5
'EI~~trical Permit Application
22~,l<'ifth Strcct+Springlic}d, OR 97477. PH(541)726-3753+ FAX(54t)726~3689
1~!'-r~"'>;'J"'''''lf,;;{~~''';!;~'''''''T~T~.iF"~~~':' ll';l\._ -; t ,w" ''''I
fl'J~DERARTMENTUSE:ONLY;'j" .
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L.M.. I COMZ-OQ8'-O 10'62. I
-.... __ PermIt no,:
I Date2S -5 ~O '7 I
CITY OF SPRINGFIELD, OREGON
lJ
This permit is issued u:'der OAR 918-309-0000. Permits are nontransferable, Permits expire if work is not started within 180
days of issuance or if work is suspended for 180 days.
lfo{?<(,:,<:~;LEOC)l.L:',:GOVERNM ENT~4rAPPROVAL;'~~':'~:;;;:""'1 ~;1!l1",;)\r~:k':''''''_ >,' F,EE;;SC H EDU L:E" d'\,,::, ::'.J.'"y'I,I;\f.., ~~I
I Zoning approval verified? D Yes D No I ~"'1-x.1">",~i~."!~,;;<-".\_<:.~_~-'[A~,,>,):,,~" 'It';"''''-'1.:~::I~';\"::!1 f~€osf"'-:'~I ~~Total~'1
!Null!bcr.oCmspcctlOnsper"tem'('),\;:1 Qty; V", ,0 ,,' ,. f ,',
Ij~;~:;:;:~;i~~TEGIR~'~~~::::n~,[RUr~~~:::;:I~~~j I'~:;;:e::~, :::::it::;:i;;~:;';~:d: '.".' .:1,ea",," -,cos 7:e'1
1,;;-,,,i\%f~JOB\iSI1;E1INF,ORMATION~'AND~~ocATIONf~j',~l:dI 11,000 sq, ft. or less (4) $134,00 $ I
I '7 ~ 6 I Each add;!;onal 500 sq, fL Dr porl;on $ I
Job site address: ,:> ') 2 q; , Ate..i-Vl\ Y <;. r thereof $ 25,00
I City: '.5pri'rl~{l.li I State: DL I ZIP: "I,Y11 I Limitedencrgy(2) I I $ 32,00 $ 3.2-1
1;~ri;"1>1\-~DESCR'P;r'ON:i:O"5\wJ~;:~:~'>;4:~jt~~ I ~~~~I~~ns~~~~~r~~ ~e~~~r (~)1Ddular I $ 63,00 $ I
1I/1~<;IfI2./JJJ.A rVJI"1 fIoleL. /~ ,.,1, I Services or feeders: installation, alteration, relocation
, "I,,29Q!2"psorless(2) >( $ 61,00 $ 25/1---
""o[ ..,,'..~ I
~~~~~f.~j),~'iP'Rdp.ERTN~OWNI;R~UiS:':d~~.I~,~~:,:~':jffti~' 'C. C20)L!?J~olaJnps {~~"'I,';_ , Z $ 95.00 $ / 90
I Name: E \I l La.WC;"L'\ (~Q k" \lL\J0\.li:~f/~ ~,N21ito~.Q9~{";p1,r(2)jrenc::f?U 10 I I $158,001 $ I
I Address (;.,;;1 I tJ ^"4\kv- ........,,\~: k. .S'6lf~cf~~IfMip:1J.rI"oog~~g\'12)'lre~~~;~ily I I $205,00 $ I
I City:' '<; l}.,Kr, ,\I.. I State W~ r ZIP"l\~'t{<\; ~ellQ.y,-;');,qoo'iiings<9rr:0if(i)),O;;';? it $469,00 $ 4j, ~ I
( ~~f( " ''v,,,' f~ 'C I U/
I PhoneC:;OC, b'.i.lY-II/D I Fax:!,c!t ~_ l?~I(ri R~C~~SC)?~~;!~;~~~t~v~/Sbv $ 63,00 $
[E-mail: b.l\\\IJi?~c-..c...J...\Lt\Lft-.\Te~gr30.~~~~I~eso.r;J~e.~!~s:lIIsfal/aflOn.al1elatlOll felocallOll
This installation is bCiirg made on residential or fam1 property I 200 amps or less T2!!' -q -iJ-t-i ~ tiJ.UU ; .) ll)~-
owned by me or a member of my immediate family, This I 201 to 400 am, ps (2) '~~
property IS not mtended for sale, exchange, lease, or rent. OAR I -,
479,540(i) and 479,560(i), 401 to 600 amps (2) $126,00 $
Sig~ature: : '", I Over 600 amps or I ,000 volts. see s~rviccs or fceders section above I
1&~;d;~,E;~i.CPNtAAcrrOR;;iINSyA([ATION,'~~~.<-~;~.Jft~:"j\I I Branch circuits: new, alteration, c).:'ension per panel I
I Businessllame: Ac!vtlt1~.j:' I~,.",- -I \ t4~ <i~ S'~~ pJ..,a. Fcc for brancfl circuits with purchase ora service or feeder fee: I
I Address: /J'Ibl (:, Mp,,+GllMI'YV I Each branch circuit Is1'i I $ 6,00 I $ ~~cI1
I City: 5~kAt\o I State: WA-. r zflro~.b I I b,Fccforbranchcircuitswithoutpurchascofaserviccorfcederfec: I
I Phone So.">. '.~:) 1 ~~ < 4> I Fax S"O'l SJ~~ q~.ml SIHAII'!!:SB<filj41lf!!;~fU~!4E WORK' I I $ 55,00 I $ I
I E-maIl r\.\~\-\/r:t..v\D<ro:>a.d....Ii.<.+{.itV(13~IZED UINDmff<l<l!~,h<!/Ii!ifl>fmqhl$-q,;;OT I S 6,00 $ I
I CCB license no: '7 R;:J R ~ 1 BCD license no,Cut!lJl!',s P.ll~1 0 R\lGcl\l;M\,,\Ml~D,rFill1J/,/eeder nol ine/uded I
I Stgnmg supervISor's license no,: t{q 1 'L. ~ IOU I\Y p, :Til~\;lj,I)"mp oTlrngal1on Circle (2) I I $ 63,00 $
I Print name of signing supervisor: Edil/liArl ~ ..J;,e5dA- I Eaeh sign or outline Iigh!ing (2) II a.1 $ 63,00 S/S/'p
I Signature of signing supervisor: ./ /T ,_IJ J 1/" I Signal.circu!torali!TIitcd-ener~paneLI_l I ~ i3.00 I 5: ~3
~ m.JM_I1~l!..77h..vJd'- allerahon, or extensIOn (2) I~ I'
. I E~chadditionalinspectio~:(l?"""" I" I $56.00 I, $
, ~ 1"""=Jc, " '%Wt""'<:~j'r';''''A'''ririirIC'A'N"'T,tii'SE<<C'li'''9t~;...P~','',;.. I
"C~,,,,:;,';}U ~~, ro:r,;L; , '1\<<',Ur,::r~Jl.~,.h~h'>-f",'"_''''' ,'~
""... ~ 1\\.(0' (A) Enter subtotal of above fees I _J - -',
~ ~'\.~\ (Minimum Pcrmit Fcc $58,00) $.:..{>.I~Z-:/,_'!
\>.....~ ,,)oJ,.O... j(B)EntcrI2%sureharge(,12x[AJ) $\/5:7'7'':''1,
~ U ' I (C) Technology Fee (5% of[AJ) $ " 'b:>lf!!?' '"
~.~~ I TOTAL fees and surcharges (A through C): $ /F~~~!,Cj' '1
~ \..~
440.2584,).(9/08/COM)
225 Fifth Street
Sprin,gfiefd; Oregon 97477
541-726-3759 Phone
City of Springfield Official Receipt
Development Services Department'
Pu!Jlic Works Department
Job/Journal Number
COM2008-0 I 082
COM2008-0 I 082
COM2008-0 I 082
COM2008-0 I 082
COM2008-0 I 082
COM2008-0 I 082
COM2008-0 I 082
COM2008-01082
Payments:
Type of Payment
Check '
cReceintl
RECEIPT #:
2200900000000000880
Date: 08/05/2009
Description
Penn Serv/Fdr 200 amps or less
Penn Serv/Fdr 20 I to 400 amps
Penn Serv/Fdr 1000 amps/volts
Add, Alter, Extend Circ Ea Add
Sign - Outline Lighting Each
Low Voltage. Commercial Indus
+ ?% Technology Fee
+ 12% State Surcharge
Paid By
ADVANCED ELECTRIC AND
ALARM
Item Total:
Check Number Authorization
Received By Batch Number Number How:Received
djb
1487
In Person
Payment Total:
Page 1 of I
10:25:23AM
Amount Due
2,511.00
190,00-
46900,.
9,204,00'
756,00
32,00
658,10'
1,579.44
$15,399,54
Amount Paid
$15,399,54
$15,399,54
8/5/2009