HomeMy WebLinkAboutPermit Electrical 2009-9-24
Electrical Permit Application
225 Fifth Street. Springfield, OR 97477tPH(541)726-3753tFAX(541)726-3689
I"~,..,...."-,>...,..,....",.,,,,~,,. >. -'.,.." -, ,',-...._,..... ,.,'-- '. . -,-. ,
, :;,;XiDERARfMENi<uSEONLy.f.:j
[' ;';";"'''''/;[/_'''0 ;':/~, ,)-,
Permit no.: l~ ~, . ( ,
I 9 I() ~ I
Date: / d- q
Tbispermit is issued under OAR 918-309-0000. Permits are nontransferable. Permits expire if work is not started witbin 180
days of issuance or if work is suspended for 180 days. .
I !j~';';i,';', 'H\!E0G;;L:r.G0",EBIIIIVIEIIITWAF1F'R:0YAIf':t:~S\)i!';'~TI';\);\?lX;1
1 Zoning approval verified? 0 Yes 0 No I
1~~~M~',~\~~'0f1'~i;~J;ATEG.o R~~KOF,)tG,ON $mB.U.~;tl.ON8;fl\~~t'i~j'~i:.\;?:;.~X~1\,
~~:~~~~~JmE91IN~~R:~~$7;&;ANQ~I~~c~~7~~r~~~};l1~~1
I Job site address: ~C;;:;- ~ Sfrt>e+ . I
I City: Spri...oJ\'e\('~ I State: 0(2., I ZIP: Q1'\T1- I,
1 Reference: U I Taxlot: I
Ire"";.;,,:,.,, ';;::\";[)ESCRIF'TION\;;OF;;;WORI{:!Jkj,~'r.~'t,:'!,\~:;;;r;1i':*'z;1 .
I !2eolo.ri'lI\ro- Elec.1n'Q Brf?C\JIPI Pox /..OJ.!., I'1Pi I)
I t'l:fO.
I L' ,. " ,',;PROF'ERT'{,'9WNER ",
I Name:I?n.m>H:-.J-ArrIfJl'l A,~~
I Address: ~S''f Ol,O~ <tf-l-Y-e("=l- .
I City: Spn'~~'l>lrl I.State:(JR
I Phone:S41-l>lC\ - ~33~ I Fax:
I E-mail:
This installation is being made on residential or farm property
owned by me ora member of my immediate family, This
property is not intended for sale, exchange, lease, or rent. OAR
479.540(1) and 479.560(1).
signature~1,,<-_-;
I.. ":;:':'CONTRACT:.~At"'ATION,i,. .'.:-:-< .,'
I Business name: ~
I A4dress: ~
City~ ~te:
Phone: :7------.J Fax:
I E-mail: / ~ .
I CCB li~no.: I BCD licens~
I ~g supervisor's license no.:
I Print name of signing supervisor:
J Signature of signing supervisor:
, ., . 'I
:- . ,,-~ - - '. .~ .
.;;-.." .
I
I ZIP: 't1LI:rt-
I ZIP:
~
440.2584-J (9!08!COM)
If:~{~h~~~~~~~4~~1'~~ffl:~F,;E:_E;~~~"OH_~_P.OJ]I;~~~ilt~'~~'~~~i~
1~;~~',m~~:~f:~!r~:~!~~1~~~te~~~iVj~::~~<}]~~~1IRtr~:1~~~~~1~t~J.<~11';{~~~~t~~-!_t)
I Residential, per unit,'service included:
1.I,OOOsq. ft. or less (4) .
I Each additional 500 Sq., ft. or portion
thereof ,
1 Limited energy (2) $ 32.00 $
I Each manufactured home or modular $ 63.00 $ I
dwelling service or feeder (2) .
I Services or feeders: installation, alteration, relocation I ~
1 200 amRs or less (2) / $ 81.00 $ 0''/,1 .
I 20 I to 400 amps (2) $ 95.00 $ 1
I 40 I to 600 amps (2) $158,00 . $ 1
'I 601 to 1,000 amps (2) $205.00 $ I
lOver 1.000 amps OLVOItS (2) $469.00 $ I
I Reconnect only (2) $ 63.00 'I;
I Temporary services or feeders: installation, alteration, relocation
I 200 amps or less (2) IX $ 63.00 ~
1 201 to 400 amps (2) $ 87.00 $ 1
1401 to 600 amps (2) $126,00 $
lOver 600 amps or 1,000 volts, see services or feeders section above
. ..'.1 I Branch circuits: new: alteration, extension per panel
f I a. Fee for branch circuits with purchase ofa service or feeder fee:
I I Each branch circuit I $ 6.00 1 $
I I b. Fee for, bra~ch circuJts without purchase ofa service or feeder fee:
I I First branch circuit (2) I I $ 55.00 I $
! J Each additional branch circuit J . $ 6.00 $
I I I'yIisceUaneou~ fees: se"rvice or feeder ;yo! included .
I I Each pu~p or. irrigation circle (2) $ 63.00
1 I Each sign or outline lighting (2) $ 63.00
I ] 'Signai circuit or a liinited-energypanel, $ 63.00 $
alteration, or extension (2)
1 Each additional inspection: (I) $58,00 $
1[11;\i~~m~~~~r~j:~gl~fC&~Nif;Wtu.s)~~~jtilt,:~i~~~il{A~~~ittf~~r:~~:.1(1
I (A) Enter sUb,totai of above fees IGI j-.J
(Minimum Permit Fee $58.00) $
, , ,.-
,I (B) Enter 12% surcharge (.12 x [AD $ ..-Lll 0 '>
1 (C) Technology Fee (5% of(AD $ 9.17 J-
1 TOTAL fees and surcharges (A through C): $ (/4-111
$134,00
$
$ 25,00
$
$
$
Status
Issued
CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2009-01422
ISSUED: 09/24/2009
APPLIED: 09/24/2009
EXPIRES: 03/24/2010
VALUE:
. 225 Fifth Street,.Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 557 20TH ST
ASSESSOR'S PARCEL NO.: 1703361308001
Springfield TYPE OF WORK: Electrical Work Only
TYPE OF USE: New
PROJECT DESCRIPTION: Replacing electric breaker box with new one,
Residential
Owner: AVERY BARRETT & ANGELA
Address: 557 20TH ST
SPRINGFIELD OR 97477
I CONTRACTOR INFORMATION 1
Contractor Type
Electrical
Contractor
OWNER
License
Expiration Date Phone
~UILDlNG INFORMATION'
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
# of Stories:
Height of Structure
Type of Heat:
Water Type:
Range Type:
Energy Path:
Sprinkled Building:
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Occupant Load:
n/a
I DEVELOPMENT INFORMATION 1
. Frontyard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
REQUIRED PARKING
Total:
Handicapped:
. Compact:
I PUBLIC IMPROVEMENTS 1
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes: NOnCE: ATTENTION: Oregon law requires you to
THIS PFRnR''r n,. _ fnllnw rules adooted bv the Oregon Utility
IiU f NOR/ZED -, '''LL tXPIRE IF T .., . Notitication Centor. I nose rUles are senorm
COMIVIENC UNDER THIS PER HII.vaIuation DescriDtion I in OAR 952.001-0010 through OAR 952-001-
ANY 18 ED OR IS ABAN MIT '" IVU / 0090, You may obtain copies 01 the rules by
D .. 0 DAVTPr::Rif"C~ DqNED FO~:per Sq Ft Square Footagelling the cpntp.r. (Note: the teleohone
escnptlOn ype 0 - onstruchon '1' I' B'd A b 1 thValuegon Utl'I,'tDate.Calculated
or rou tip Icr or I mount,n er or b Vlv J l~vl"'''''''''U'''''1
Center is 1-800-332-2344),
Sidewalk Type:
Downspouts/Drains:
Paee I of2
Ge"!!'I~IEWDj' ,""~.. ,
- '7;"':~~\:,,::!01'! T:~j;nr';-;j""';:"".~'1!"~
"I "
CITY OF SPRINGFIELD
Building/Combination Permit
Status
Issued
PERMIT NO: COM2009-01422
ISSUED: 09/24/2009
APPLIED: 09/24/2009
EXPIRES: 03/2412010
VALUE:
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Total Value of Project
I Fees p'~id I
Fee Description
+ 12% State Surcharge
+ 5% Technology Fee
Perm Serv/Fdr 200 amps or less
Amount Paid
Date Paid
Receipt Number
$9.72
$4,05
$81.00
. 9/24/09
9/24/09
9/24/09
2200900000000001090
2200900000000001090
2200900000000001090
Total Amount Paid
$94.77
I Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769, All inspections requested before 7:00
a,m. will be made the same working day, inspections requested after 7:00 a,m, will be made the following
work day,
I Renuired Insnectirn~,1
Electric Service: Approval required prior to utility company energizing service.
By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springfield and the Laws of the State of Oregon pertaining to the work described herein, and
that NO OCCUPANCY will be'made of any structure without permission of the Community Services Division, Building Safety.
I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project.
I further agree to ensure that all required inspections are requested at the proper time, that each address is readable from the
street, that the permit card is located at the front of the property, and the approved set of plans will remain on the site at all
. times during construction.
~~---:J'U_-
Owner or Contractors ~ .
9 k.cl Iocr
, {
Date
Paee 2 of2
-'
.' ,
. .
. .
, .
" .'
" .'
. ,
Construction Co'ntractors Board'
700 Summer St NE Suite 300
PO Bnx 14140
Salem OR 97309"5052
Phone: 503-378-4621
Web Address: www.ccb.state.or.us
~. ','
Permit #: (! Cf ---/.~' d d- ,
Addres;: . l ;;<)-7 -)::0 o---t.h
IssuedV~ Date:
,;
~
7}/2-- y/o'7
,
"
Statement: Information Notice to Property Owners
About CO'nstruction Respon~ibilities
,
,Note: Oregon Law. DRS 701.055(4) requires residential con;truqion permit applicants who pre not
licensed with the Construction Contractors Board to sign the following statement before a building
permitcan l<e issued. This statement is requiredfor residential bililding, 'electrical, mechanical and
plumbing permits, Licensed architect and engineer applicants, exempt from licensing under
ORS,'lO 1.010(7), need not submit this statement. This statement will be filed with the permit.
.- .. t- I
., . .~' . ,-. +' '. - . ~ . ! . . -
Fill in the appropriate bl~s'all<(initial boxes I and 2"arid eitherb,ox3A"or 3B:
. . . h
. '
01.
o
I-own,reside in, orwill reside in the completed structure.
2. . lunderstand that I must become licensed as a construction contractor if the structure.is sold or
. .':- offered for sale'before or on completion. .
.0 . 3A. My general contractor is
(Name)
(CCB #)
. . '. . . . -. .
I will instruct my geri'eral.contractor that all sulicontractors who 'York'on the structure must be
, licenseclwith the Constructio!1 Contractors Bqa,qt .,':' .
~3B. IWillbemy~:generalcontractor. .(eL~lV~b)
IfI hire subcontractors', I will hire only subcontra6tors licensed:with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is,
. licensed with the CCB and will immediately notify the office issuing this building permit of the
naine ofthe contractor. "
I hereby certify. that the above information is correct and that I have read and do understand the Information
Notice to PropertY Owner~aboutConstruction Responsibilities o~ tlie reverse side of this form, .
~~~~'___ ~/2ij/()9
..- (S~rmit applicant) '. (Date)
(white copy to issuing agencY permit file, p(nk copy to applicant.)
,'. .' .,
.'
P'~"_';L~wner,doc 06.01-04
. ,
_ ._._._ ._,4'_ _ __ _ _ ..~.'~ .--.,.. . . .
- . -__~... -'-'..i"'"\
^ctipg-as~ Y(n~r__9wu:Qener~IContractor? ;
_-"""<. ""\',..:' .~'\...-,~~:,-.___.... .,',..;.' _._4;...~.".'.
.. .,t_ INFORI\!IATIQN ~OTICE TO PROPERTY OWNERS r.. ,
\"~ ~\,;. ' _._~130UT cq~~!,1~',UCT!qN:~ESPONSIBILJTIES ., ';':' " ',';,"
.
. '.\"
. ',1
'.
NOTE: This Information Notice to Properly Owners about Constr~~tlon Responsibilities was d~veloped by the
Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legislature.
. :,-.~,' . .'. . . " "." -~..;..;~ -i. . . - , . ... f'
If you are.~cting as your o~ cql).trtlctor to construct a 'new hot)1e' or ma~e a subsfantial improvementto an existing
structw'e, you can preventmany 'problems,by being'aware;of.the'followitig.responsibilines and,concerns,
Employer Responsibilitie~
....1.. . .1\',' (1~':_~' .\'. ~'.;... . .,'.'\':. _ .,j">' . i"-'~ ',. .. :"" .,..... ". .
Y ou ~iI1, in,most instllnces"be ruled to,.be an ':employerc;, ap.d th<< contr.actors you contJ;act with ~ilf be "emp)oyees" if
- - . '. ". .. -. - ....1 ~ . '. " ~ .. - .... '
you use contractors not licensed with the.Construction Contractors Board tO,do labodn constructing or to assist in the
__ '.~ . t' \ . - .-. ..... ,~'~('~~' (_..~.. . '.~.~ ~"......:, .... ~;..,.... ,..,~' '..'
construction ?ri!J1pr?~eIl1'?I1~~f,~ res~?<i~1 str;?,ct)f~.:..A.: the~InP'9y,e,r'rr:~.~ust,f'l-~~lyWi~~ the ~~~OWing: .
. ..... ,~.-\ 1..C~"',,\, ;'},', ~~"...~.,\.,\.h\ .,\,!\/~,,!:,~,,. '.'\.;~:l"\~' ...t:~,~.-{..~.;.,..~",,,,"..'....(_\-.~t..r .'
Oregon's Wlthholdmg Tax Law: As an employer, you must WIthHold 'uicome taxes from employee'wages at the tIme
employees are paid. You will be liable f9r the tax paYJl1ents. evenJfyou don'! aCfUally with!1old:the tax from your
employees. For more information; call tlle Deparii'nerit'6fRevem'1'e at 503~j'78'4988;"'1!;". ,t,' .,' :'-'4"' 'cr' .. ,
"Unemployment Insurance Tax: As an employer, you are'niquired'to'pay a taX;for iitielllployinent insurance purpos~~ ,.
on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488,
, ~.. # .
. ':' I':'.'~'r.- .,'..... :. -.; .~ ...,. .,f.'.' - ,_ '..1../I:''o '.
; . . " ';'~.. :t. . .
".\:1 ;
.-: . ,t. .':,.:
e
The Oregon Business. Identification Numbt;r (BIN) is a cOIt1bin~ ,.n!Jlllber, ~or _ both Oregon. Wjthho!ding and'
. Unemployment Insurance Tax, To file for a BIN, call ~03-945-8091 or www.dor.state.oLus/formsDav.htmll for the
appropriate forms. . ,
.l .' , !; J ...' / '. "~ l.[).... .1-,.
,.
. , '.; ~ .. ~:"'1'1!;~ ;' - .. . '.
Workers' Compensation Insurance: As an employer; you are subject to'the Oregon Workers' Compensation Law,
and must obtain workers' compensation insurance for your errq>loyees. If you fail to obtain workers' .compensation
insurance, 1o~ <t~ul~ be sub'j~tt top6n;{1ti~s ~rid be' ll~1llg fo(~ii'dlaifu' costs if one 'of'your empl()yee,sis 'Ji\jured on the
job, f'or mordnformation, call the W~rkers' Compen~iion Divisioh'at-tJieDepartrm\nt of GOIisuTmir and Business
Services at 503-947-7815, (. ; . . .' , .
':-S'l>'~ \ ~~~- ~- "-
D,S, Internal Revenue Service:'--As' ~'n~nw.i&ye~;~~ m~i~\viilihold'fe'defa:r income tax from' empioyeds' wa~~~~
You will be liable for the tax payment even if you didn't actually withhold the tax, For a Federal EIN number, call the
IRS atl-800-829-4933idf~visit'their'web site'atw:\mYk~ov,. '., -'., _.' " . ,':'. ~.;:, ",.. " ," .
'. . ; ".~\').;"~...4c;-~t!..,..:,:. . . .It;,.... ._'.' 'I "';. J . _,.,' -if...:.~".,,' ,"-- . ',.:~
, " '~'JOthei: R~sponsibmties an<<:J-Areas QfConcern~ "t, '. .'...
Code Compliance: As the permit hoWer for this project, you are responsible for l'esoiVihg'any'[ailure'lo'meet code
requiremcnts .that may be brought to your attention through inspections. ,
.' :', '1 '........,' '..:, ~. ~""..... "'",.:<,:,:' "-:1.,_'_"", ....', ....;~l.,_..'""';.. .--i,"~':';~J:)~'<.
Liability and Prnjlerfy' Da~~ge Insuranc~: ; C6htacf yo~r:in:sui'a~c'c' agent -to 's~e 'if'yolj 'haveade'qliate;ns~ratice .
coverage for accidents and omissions such as. falling tools, paint over spray, water damage from pipe punctures, fire or
work that must be redone" . '" ..
\) \. '.).~ \ \ J . ..... ~'-. '\..,' _ ~ ~ .
...- ,~. -, - - ---- .' .."~.-.}.-v-j":~. .
Time: Make sure you have s~fficient time to supervise your employees:' ',: /, ,; ., " . -' 1.(. _:' :; .
- ~
..' . .' .. t. . . ),)t' ... \ .,7,.... .I.f . '~:1';).::-'.. .~.'., . ' -'. ,.'. . . .
Expertise: Make sure you have' the skills' to act as your oWn general contractor, to coordinate 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 (503-3784621) or write the agency at PO
Box 14140, Salem, OR 97309-5052.
, ..'
Property _ owner.doc 06-01,04
225 Fifth Street
Springfield, Oregou97,477c,
541~726-3759 Phon~. ...'
Job/Journal Number
COM2009-0 1422
COM2009-01422
COM2009-01422
Payments:
Type of Payment
CredjtCard
cReceilltl
RECEIPT #:
......----~I.~"C~,,"~'-... ,', ,"
db _ .
1 '.. ~:
.:--...'.'.. .
, ,
.. -, ,.".:
- ... '. .,
....-... ,,;.,. ...~.._. ,-,'.- '." -
City of Springfield Official Receipt
Development Services Department
Public Works Department
2200900000000001090
Date: 09/24/2009
" ....'
Description' '.".
Penn Serv/Fdr 200 amps or less
+ 5% Technology Fee
+ 12% State Surcharge
"'. .' ;.~ ".:" .,
'Paid, By.
BARRETT AVERY'
, ,..
..:";'. ..
"
l1em Tolal:
Check Number Authorization
Received By Batch Number Number How Received
njrn 023604 In Person
Payment Total:
Page I of I
1:00:5IPM
Amount Due
81.00
4.05
9,72
$94.77
Amount Paid
$94.77
$94.77
9/24/2009