HomeMy WebLinkAboutPermit Electrical 2009-9-4
Electrical Permit Application
I .
~i-1I~~::~~~f;':^1
I Date: 0..4.61 I
225 Fifth Streett Springfield, OR 97477tPH(S41)726-3753t FAX(541)726-3689
This permit is issued under 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.
I,.' ; . LOCAC:'GoVERNMENT.JAP,P,ROI;t.l\L- ,."--,,
I Zoning approval ve,ified? DYes D No
:CATEGORY,i,OF',rc0NSTRUC.TION,'",",:1?irrr':;,",,',;:
~ Residential J D Government I D Comme,cial
1":;';:;::.JOB,SI;rEiINF'oRMATION~AND,,jLOCA;rION~;L;'.":
I Job site add,ess: (,Oj3 GRAV:i70NE lOOP
I City: Sftlfl/o,HcL.Q LState: OI? 1 ZIP: cn!7!~....
I Refe,ence: \'101.~~-o 1 TaxlotjJO?U/
IJ";;.;~~,-,J"'~;.;isJDESCRIPTION~OF, :WORK'i{7"i.d"= -'4,:.'JT~
I /1I.57"ItLL 1-107 TI/[j C,tfc-v 17
i'i:"":"':~ir:"\':li!,i;!l1illillikPROP'ER;ryiiOWNER'lfj~'iii'1i:4.'i!,;<;rr;i;;:t': ,,;::/
1 Name: JASUN M'NCH",I - ~~
1 Add,ess: bOQ3 G(lIlV5To"'~' L. oor
City: SPt''''bncJJ I State: OIL I ZIP: ql~l~
Phone: 5~1-S-oS" 'l'i'l) 1 Fax:
I E-mail:
This installation 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.~1)k\)~79 60(!l. .
Signa~
I,:' "1;7"{' ~RI\c::Jl.lR"INSTAl:l!A.TION~:-,";;:'i'K":;jC'''';'''1
1 Bu~ness name: I
1 Add,ess: I
1 City: I
1 Phone: 1
I E-mail: 1
r CCB license n;: I BCD license no.: I
I Signing supervisor's license no.: I
I Print name of signing supervisor: I
I Signature of signing supervisor: I
I State:
1 Fax:
I ZIP:
ATTENTION: Oregon law re~~~Q-""
follow rules adopted by the Ore~; UI~
Notification Center. Those rules a,e 5~~t)..
in OAR 952-001-0010 through OAR 952-~'
0090. You may obtain copies of the rules uy
calling the center. (Note: the telephone
number for the Oregon Utility Notification
Center is 1-800-332-2344).
440-2;84-1 (9/0B/COM)
" i _"f-~;;f;EE.2SCHEDULE";~', _'
~~,' ':~'~tt,~fi.~s~e~ti_~n~ ~~~r~i~.~li( (1\~J IQ.ty.I':~,:'~eoa~~.:~1 :.. Tcootsal' f; ~
-'.111,' -i.'V,,"n.". "W.,',.. },.,,,lI .,' __,,'fe;,", , C~~~. . "...,' ,Y",'''. ',...d-';_ ...."
I Residential, per unit, service inclu'ded:
11,000 sq. ft. or less (4) $134.00 $
I Each addilional500 sq. fl. or portio~ $ '25.00 $
thereof
1 Limiled energy (2) $ 32.00 $
I Each manufactured home or modular $ 63.00 $
dwelling service or feeder (2)
I Services or feeders: installation, alteration, relocation
1 200 amps or less (2) $ 81.00 $
1 20 I to 400 amps (2) $ 95,00 $
1 401 to 600 amps (2) $158.00 $
I 601 to 1,000 amps (2) $205,00 $
I. Over 1,000 amps or volts (2) $469.00 $
I Reconnect only (2) $ 63.00 $
I Temporary services or fceders: installation, alteration, relocation
200 amps or less (2) I I $ 63.00 I $
20 I to 400 amps (2) I 1 $ 87.00 $
401 to 600 amps (2) I 1 $126.00 I $
Over 600 amps or 1,000 volts, see services or feeders section above
Branch circuits: new, alteration, e~tension per panel
a. Fee for branch circuits with purchase ofa service or feeder fee:
Each branch circuit
1 $ 6.00 1 $
b. Fee for branch circuits without purchase of a service or feeder fee:
First branch circuit (2)
Each additional branch circuit
II I $ 55.00 I $
I I $ 6.00 $
j3~
. '-J
(,.. -
Miscellaneous fees: service or feeqer not included
Each pump or irrigation circle (2)
Each sign or outline lighting (2)
Signal circuit or a limited-energy panel,
alteration, or extension (2)
Each additional inspection: (I)
$ 63.00 $
$ 63.00 $
$ 63.00 $
$58.00 $
I (A) Enter subtotal of above fees
(Minimum Permit Fee $58.00)
I (B) Enter 12% surcharge (,12 x [A])
I (C) Technology Fee (5%0f[A]) ,C
NOTICE:JI ;~~AL fees aud surcharges (A through C):
THIS PER ,'- fiLL EXfFn!: IF ,He WCfif\
AUTHORIZED UNDER THIS PERMIT IS NOT
COMMENCED OR IS ABANDONED FOR
ANY 180 DAY PERIOD.
$to\.cP
$ 4..~~
$ ?IDa
$1 \'~ 1\
/'
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
-. ,~Q""~.~.._":.'.I._~'.
- " :
w".
".,.d _'.C"_'"
City of Springfield Official Receipt
Development Services Department
Public Works Department
Job/Journal Number
COM2009-0 13 13
COM2009-01313
COM2009-0 1313
COM2009-01313
Payments:
Type of Payment
C,editCard
cReceint I
RECEIPT #:
1200900000000001030
Date: 09/04/2009
Description
Add, Alte" Extend Cire
Add, Alter, Extend Ci,e Ea Add
+ 5% Technology Fee
+ 12% State Sureha'ge
Paid By.
KARA MINCHIN.
Item Total:
l.:heck Number Authorization
Received By Batch Number Number How Received
LLH 123902 123902 In P,erson
Payment Total:
Page I of I
10:31:07AM
Amount Due
55.00
6.00
3.05
7.32
$71.37
Amount Paid
$71.37
$71.37
9/4/2009