HomeMy WebLinkAboutPermit Electrical 2009-9-17
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Electrical Permit Application
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225 Fifth Street+Springfield;:OR 97477+PH(541)726-3753+ FAX(541)726-3689
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I Permit no {let - o()o35 I
I Date: ;t,- /7r- 09
This permit is issued under OAR 918-309-0000. Permils are uontransferable. Permits expire if work is not started within 180
days of issuance or if work is suspended for 180 days.
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".ivl.r0CAli::GOVER.NMENT':IAp'RR.0Yfi..G;;f;\\1P;~;:]!~'\\1iGI :;.;(c;?:f!(i1i!j~i{Q~wlfii!J./.'4i#1EEE~SQI'IEbUl!E~~~~i!1!t_~~
I Zoning approval verified?, , D Yes 0 No l:i'I~;;;~e~1~t;i~i~~c!i~~s:~~~;Jt;iii~(S:9~EIQW:1 :;fii~!;~'i;I';!ot'i~UI
if{;;;;:~:~:f;~~l1EGT~i~~~::~:~"(RUr~O~:;;;~~:;'dt!, I' I' ;:;;~:'n~::;,'~:;::'~:::;:i~~';:'CI~~;~~ ,..",",i''',e~.'''~, rc, ,c,ost",: 1 .
1~1~1toBli:slmEi!INI;:QR.MAmloNIYANDflI!0QA:T:I()N~ml'\tlil 11,000 sq. fL or less (4) $134.00 $ 1
I. d('~ 71. \ J - ,. ....... 1 I Each additional 500 sq. ft. or portion $ I'
Job site address: -({IV "'" Sr. thereof $ 25.00
1 City: SOr:"" ,<:\~ /& I State:' oR. I ZIP: q 7 "17 f 1 I Limited energy (2) $ 32.00 $ 1
1~~~{;~;,~~c~,:,J:~?D1~1~~ONrtOF':WJ;~~,~~~~~.);,,:11 ~~~~I~~ns~~i~~~~ ~~~~r (irodular $ 63.00 $ I
I I I Services or feeders: installation, alteration, relocation I
1 I I 200 amps or less (2) $ 81.00 $ 1
I , ." , ;PR()I?,ERTY.OI/VNER, I I 201 to 400 amps (2) $_95.00 $ 1
I Name: ~&c\ \t.~ \ 1 I 401 to 600 amps (2) $158.00 $ I
1 Address: y.fs:O 71 ~ )-/-. 1 '1 601 to 1,000 amps (2) $205.00 $ I
1 City: .sfl;'^~ t:.'tlJ.. ' 1 State: OIL 1 ZIP: <] 7 41~ I lOver 1,000 amps 0; volts (2) $469.00 $ 1
, Phone:5'11"96 _ '110 K- I Fax: 1 I Reconnect only (2) $ 63.00 $ I
! E-mail: ~~t-(,o...sSO ;fi) ~ h.)~~; \ . tVV"' I I Temporary services or feeders: installation, alteration, relocation I
Th" II' . b . ~ d 'd' c I 200 amps or less (2) $ $
IS msta atJOn tS emg ma e on reS! entia! or ,arm property 63.00
owned by me or a mem~er of my immediate family. This I 201 to 400 amps (2) $ 87.00 $
property is not intended, for sale, exchange, lease, or rent. OAR I I
479.540(1) and 479.560(1). 401 to 600 amps (2) $126.00 $
Signat~ _-;-, ...............~ _ lOver 600 amps or 1,000 volts, see services or feeders section above
I, .. ':'d,C0NTRACli.OR.;:'INS1:A'H--II'TTON\:, '".,..::':'1 I Branch circuits: new, alterallOn, extensian per panel
I Business name;-\(O~ 0.... \;\.. Q.C(... "> 1 I a.Fee for branch circuits with purchase of ase'rvice or feeder fee:
1 Address:, 'if>O (t.i1 ~ r;;/. I I Each branch circuit I $ 6.00 I $
1 City: SI1 I \~l~lJ 1 State: D VL I ZIP: "/7'17& I I b. Fee for branch circllits without purchase of a service or feeder fee:
I Phone:J1!j -S'ii - 9/0 I::: I Fax: I I First branch circuit (2) $ 55.00 $ \
I E-mail: I I Each additional bcanch circuit $ 6.00 $)
CCB license no.: I BCD license no.: I I Miscellaneous fees: service or feeder'rlOt included
Signing supervisor's license no.: I Each pump or irrigation circle (2) $ 63.00
Print name of signing supervisor: I Each sign or outline lighting (2) $ 63.00
I Signature of signing supervisor: I I Signal circuit or a limited-energy panel, $ 63.00 $
alteration, or extension (2)
I Each additional inspection: (1) ,$58.00 $ I
j~~t~~~Z~~i,Th~~~Ffg'izTC'l\Nm~(t)S~J,~~t#~~d2;~~4~r~~\w;1I~~'f;1
I (A) Enter subtotal of above fees $
(Minimum Permit Fee $58.00)
.1 (B) Enter 12% surcharge (.12 x [AD
1 (C) Technology Fee (5% of [AD
I TOTAL fees and sorcharges (A through C):
$
$
~~~
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'V'''1J''
~
$
$
$ 9;. '7'S-
440-2584,) (9108ICOM)
22S Fifth Street
Springfield,Oregon97477
541-726-3759 Phone
Job/Journal Number
COM2009-00288
C0M2009-00288
COM2009-00288
COM2009-00288
PaymeRls: .
Type of Payment
CreditCard
cReceintl
City of Springfield Official Receipt
Development Services Department
Public Works Department
RECEIPT #:
2200900000000001057
Date: 09/17/2009
De'scription
Add, Alter, Extend Circ
Add, Alter, Extend Circ Ea Add
. -B 5% Technology Fee
+ 12% State Surcharge
Paid By
TODD HAAS
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
NJM
028221 In Person
Paymenl Tolal:
Page I of I
12:33:32PM
Amount Due
55.00
30.00
4.25
10.20
$99.45
Amount Paid
$99.45
$99.45
9/17/2009