HomeMy WebLinkAboutPermit Electrical 2009-10-8
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,'fh'i~ permit is issued under OAR 918-309:0000, Permits are noutr~nsf~rable. Perm'its expire if work is uot started within 180,
'days of issuan~e or if work i~ .s':lsp~nd~d f~~ ~80 da"ys. .. . ..". . - .
~ Electrical Permit Applica'hon
CITY OF SPRfNGFIELD, OREGON
;225 -.:ifth Street+Springfield, OR 97477'''PH(541)726-375~. FA~(541)726-j689'
[":':~"':,,;I.:.OCAl'GOVERNMENTiAPPRbVAl-; ~ "1 I '" ~ "FEESCHEDUlE:.::. ,.;::"
I Zoning'ap' proval verified? . 'D'Ye~'. 0 No I' I'N' ..~. b '. 'f,::,;i' ...k 'c. "( ')' 'IQ't' 'I . Cost :' 'I ',Total'
~. .' . ;~~ ,cf ~)"~.~~~ct~~;?S p~J.l~e~,:. ,,:. ., y~ -.:, ea::-;..~ cil.sU-;:
[;':..1;;,":: ...CATEGORY.'OF:,CONSTRUCTION'" ;": ,1'1
I Resi~ential, per D,nit, se~ic~ inClu.ded: .
,'ll!2tResidential .: 1 D,Govemment', ',I 0 Com;"ercial I ' 1 $' 134.00
,',," 'JOB..SITE,INFORMATION':ANDd:OCATION .~:...":'[ '1,000 sq. ft. or Icss (4) . " $
1 . "..- I' "I.Ea~h additi?~al 500 ,sq., ft. or p,9!1ion 1 ' .
, Job site address: . / t?.:2L,- ',.... <.1' J: , ',thereof','.-',,' :.', '. ',' $ .25.00' $
kity; ~~ . .1'St~te:O~ I 'zIP: 'T' 7 L(7 711 Limited ene[gy(2) : I $ 32.00 $
1 Reference:. ,VIl1b'2.lv'\" . , ,I Taxlot.:~\C(;.J I '1 Each mamifacnjred hornet" modular' 1 $ '63.00 '$.:
'I" > . '. ~ .' ~ .. "I dwelli'.lg seryice .o~ fee?c.r (2)... ..
., .. ",'." ' .;,' ":',:DESCRIPTION :OF,,WORK~ ',' > .t.., .:',\,:", ,.. . " ' ,
'I ..~/ :L.' /) '., , ,1;'.1 sCrVice.S,or_feede'r,s': insta!laiion, al.teration, relocaii on'
. ;.-_/~~rYIC'~ " ," ." '. . ., , . .
:.....1 . . I 1:200 amps or less (2) $ '81.00 .$
'[' "'. ',.". "," 'P'R'O'PER'TY. O'W N"E' R>' "";:"',. ,:..,,[ '1 ZOI to. 400 amps (2) $ 95.00 $
" .. ." ,.,.,',..' " . . ~ . . "'''' ...:.. ~> ,..~ \." " . .
,I Name: ~~. ~;'7 ~.' 1140Ii~'600amps(2)1 $158.00 $
,I Address::/o oiG' c..T. 51=:'. ' 1 1601 to'I,OOO amps (2) I $205.00 $
1 City: <:;;;::99--Ifcl State:,r<}K. 1 ZIP: '7 7~7..R1 Overl,000am'~sorvolts(2) '1' $469.00.$
'I Phone:i;-.qI-7~~ _ '?'s 8'9' I Fax: ' . ' ,I I Recoilnect only (2), $ 63.00 $
,I E-mail: I I Tem'pora~ servi,ces or fe~ders': i~stallati.on, alteration, relocation" I
, I 200 amps or less(2), $ 63.00 $ , I
I 201 to 400 amps (2) $ 87.00 $
401 to 600 amps (2) $126.00 $
Over 600 amps or 1,000 volts; see services or Ceeders section above
This in'stallation is being made on residential ot fann property
owned by me or a member afmy immediate family. This
property is not intended for sa,le, exchange, lease, or rent. OAR
479.540(J) and 479.560(J). ' '
Signature:c:::l.-... /?., .' ',:---
[' " ,fQ'N~cT6R INSTALLATION
I Business name:
. I Address:
1 City:
I Phone:
I E-mail:
I CCB license no.: I BCD license no.:
I Signing supervisor's license no.:
I Print name of signing supervisor:
I Signature of signing supervisor:
State:
I Fax:
1 ZIP:
~
\\)4'OC\
\l- <6?rt--
(),~
440.2584.J (9/0S/COM)
Branch circuits: new, alteration, extension per panel
a. Fee for branch circuits with purchase of a service or feeder fee:
Each branch circuit
1$6.001$
b. Fee for branch circuits without purchase of a service or feeder fee: I
Iv I' $ 55.00 I $ CS I
oI,J $ 6.00 $ !'h I
I
I
I
I
I
[
$ ?j~
$ ~'~ I
$'?;~ 1
$ ~S-U
First branch circuit (2)
Each additional branch circuit
Miscellaneous fees: service or feeder not included
Each pump or irrigation circle (2)
Each sign or outline lighting (2)
$ 63.00
$ 63.00
$
$
Signal circuit or a limited-energy panel,
alteration, or extension (2)
I Each additional inspection: (1)
I _' APPLICANT USE
I (A) Entcr subtotal of above fees
(Minimum Permit Fee $58.00)
I (B) Enter 12% snrcharge (.12 x lAD
I (C) Technology Fee (5% oClAD
I TOTAL fees and surcharges (A tbrough C):
$ 63.00
$
$58.00 I $
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phoue' '
541-726-3676 Fax .
541-726-3769 Inspection Line
SITE ADDRESS: 1026 J ST
ASSESSOR'S PARCEL NO.: 1703264413700
PROJECT DESCRIPTION: 4 circuits
CITY Vi' ~rRI1~\.Ji'IELD
Building/Combination Permit
PERMIT NO: COM2009-01487
ISSUED: 10/08/2009
APPLIED:' 10/08/2009
EXPIRES: 04/08/2010
VALUE:
Springtield TYPE OF WORK: Electrical Work Ouly
TYPE OF USE: Alteration
Resideutial
.owner: : HELEN B BRUZER REVOCABLE LIVING TRU
Address: 1026 J ST .
SPRINGFIELD OR 97477
Contractor Type:: . "Contractor
# of Units:
Primary Occupancy Group: R-3
Secondary Occupaucy Group:
Primary Construction Type VB
Secondary Construction Type:
# of Bedrooms: .
,
Frontyard Setback:
Side I Setback:
Side 2 Setback:
Rearyard Setback: ..
Solar Setbacks:'
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
Descriptiou
Type of Construction
I CONTRACTOR IN~ORMATlON ,
N' 0 gon law rHl;,IlI!SeJou tExpiration Date Phone
A~TE~!!?_ ~...:~tPrl hv the Oregon Utility
.............. - - -'." -~ ~r(;l ~\:a IVI.lll
II("BumDlNG;INFORM~TION",R 952-001-
in UAt'I Jj,"".,~~,: .~bt~\~'~~pies of the rules by ,
0090, #{~~;~~O~I~~;pr (Note: the telephone Lot SIze:
calhHelght of',Structure Ut'llity NotificationSq Ft 1st Floor:
. . ...... +,-.r th?, ()regoll
nUmifY~~~'~reat1_800.332.2344). Sq Fl2nd Floor:
Water Typ~: Sq Ft Basement:
Range Type: Sq Ft Garage/Carport
Euergy Path: Sq Ft Other:
Sp~inkled Building: u/a Occupant Load:
I ,DEVELOPMENT INFORMATION I
REQUIRED PARKING
'. NOT!CEOverlay Dist:
, ~\~ne.<;t-i}\E~sll}'~HE IF THE WORK
THIS PEPpaved'DriVe-Rgct:s PERMIT IS NOT
UTHOR"cP 'j"'\'"1'\ I rll
A, %-ofEot CQverage:DONED FOR
COMMENCED OR IS AbMI~
....,...........'"'^\lDct!:lnn .
Total:
Haudicapped:
Compact:
r\l'" . '-''-' _..-
I PUBLIC IMPROVEMENTS I
Sidewalk Type:
Downspouts/Drains:
I Valuation Descriotion I
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Value
Date Calculated
Paee I 01'2
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CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2009.0]487
ISSUED: ]0/08/2009
APPLIED: ]0/0812009
EXPIRES: 04/08/20]0
VALUE:
Status
Issued
225 Finh Street; Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Total Value of Project
Fe!,s Paid I
1.1,
Fee Description
+ 12% State Surcharge
+ 5% Technology Fee
Add, Alter, Extend Circ
Add, Alter, Extend Circ Ea Add
Amount Paid
Date Paid
Receipt N umher
$8.76
$3,65
$55,00
$18.00
10/8/09
10/8109
10/8/09
10/8/09
2200900000000001158
2200900000000001158
2200900000000001158
2200900000000001158
Tota! Amount Paid
$85,41
;.,
~,
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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 Rrouired Insnectinns I
Rough Electric: Prior to Cover
Final Electric: Wheu all electrical work is complete,
By signature, I state and agree, that I have carefully examined the completed applicatiou aud do hereby certify that all
information hereon is true and correct, and I further certify that auy and all work performed shall be doue in accordauce with
the Ordinances of the City ofSpringtield and the Laws of the State of Oregon pertaining to the work described berein, and
that NO OCCUPANCY will be made of any structure without permission of the Community Services Divisiou, Buildiug Safety:
I further certify that only contractors aud employees who are in compliance with ORS 701.005 will be used on this project.
I further agree to ensure thatall required iuspectious 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 plaus will remain on the site at all
times during construction.
o--~~_.~
O~tractors Signature
,: , .
/o-d'--d9
Date
Paee 2 of2
, Construction Contractors Board
700 S,!mmer St ~ Suite 300
PO Box 14140
Salem OR 97309-5052"
Phone: 503-378-4621
Web Address: www.ccb.state:or:us
Pennit.#:
(Jq-ILj~7.""
Sr 5IFLf) ()rL -99'1~)7
Date: 16./g- M 7-
7 -f '
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Address: I cJ :;2 (p ,\
Issu~d by: ~
Statement: Information' Notice t(j, Property Owners
About Construction Responsibilities
"
Note: Oregon Law, ORS 701,055(4) requires residential construction permit applicants whoare not
.licensed with the Construction'Contractors Board to sign thefollo,,!,ing statement before a bullding
permit clm be issued, Tliis statement is requiredjorresidential b~iiding, electrical, mechanical and
plumbingpermits, Licensed architect and engin.eer applicants, exempt from licensing under
, , ORS, 7m 01 Q(7). need not s,ubmit this statement, T}zis statement will be filed with thi( permit, ,
, . Fill in the appropriate blanks and initial bOiCes 1 and 2, and either box 3A or 3B:
&~ I own, reside in; or will resi~e in the completed structure,"
_ !:d 0 ,2: I understand that I must become licensed as a construction contractor.ifthe structure is sold or
': offered for sale before or on completion.
.~.
o 3A. My general contract~r is
(Name)
(~CB #)
" .' .' . ~ '
. :" -.1 will instrucLmy geIieralcontraqtor that all subcontractors who work on the structUre, must be
licensed with the Construction Contractors Board.
~. "OR-'
J .
3B, I will be my, own general contractor,
&
,
'.~ . .
In hire subcontractors, I \Vill hire only subcontractq,s liCensed with the Construction Contractors
Board, If I change my mind' and hire a general contractor: Iwill contract with ,a contractor who is
licensed with the COB and will imrneaiatelynotifythe office issuing this biIilding permit of the
, . name of the contractor,
:' .
I hereby certify that the above. information is correct and that I have read and do understand'the Information':,
Notice to Property Owners about Construction Responsibilities on the reverse side of this form. . ,
/J '~ ~._'. - - _ it:?-7J- 09'
p- (~gnature of permit applicant) (Date)
(White copy'to, issuing agency permitfzle, pink copy to applicant.)
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Property ~ owner. doc 06-0 1-04
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Acting as:"'Y ouw'Own' General.Contractor?
(".,i~~,\,: -IN~ORMATl9~"NOTICE'TO PROPERTY 6WNE~~' ~; : ". '
ABOUT,C0NSTRUCTION.RESPONSIBlllTIES' . ',' " .~
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NOTE: This Information Not/ce to Property OwnerS about Construction Responsibilities was developed by the
Construct/on Contractors Board in accordance with ORS 701,055(5), passed by the 1989 Oregon Legislature,
. : ,. . .' i~.';; '-',", . ' -'f'::~."~"": .... .-.,~. .,.....:t.~.: ","
If you are acting as your own contractor to construct a 'new horre or make a substantial imiJrovement to an existing
. . . ~ . . c. , ' . ~ "' ... _ . . .~ . .
structure, you can prevent.rnany problems by being:aware oHhe following responsibilities and concerns,
, Employer Responsibilities
.', . '-1 _ ,'- . '. "1 ..;:.,,',;,.: ';..,1. ..~":~~__.........:....:...', _,i. ,,_.,t;I~', -,. J-j.~.~...":'-" ""1:
You will;!!! most,instances, ~e ruled to ,be an.:'ep1ployer,":and!]1e 9.011tra~tor~;Y9.\f~~~vact,~it.h>v!!r1;>e~'~WPI,?yees" ii
you use C~ntractow not ~ic,en:syd wit~ ~h~, pO~I}~!rV5-~.Wt9'1~!1;~ft?rs B~ard,!o d~ laJeor ip c!lns,~,c~n,g,~r tq,as~~~t in the
constructIOn 0': .\I11p::ov~(llf:nt of a;reN9\'Y~wl, ~t;'fcture"'.:,A~ ~~~~mIJI,o~~r, rwrnu.~t ~~mp~' ~~~h 1~~ !O~(l~I~~:
...... . . ,".~ ~ ,....-.\~_....... .{',.,\' ~,' ..-., ,',' . ,............,. ',;" \ - ,,' ;'"
Oregon's Withholding Tiu Law: As an employer, youtmist witJ\J.ioJd'income taxes rrorriemployeewages' at the tim.
employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax trom yow
employees. For more;infoimation~c~jItKe'D'epartriieiitidfRe'v~n'ile~t5(j3~378-4988:c ~:' i ;;"", ,,':i ".'i c' ,;,'
Unemployment Insurante Tax: As an employer; YOii'llr€'ieqi.lired to paya\tax for Jirtemploylncnt',insurance purpos~',; , ~
on the wages of all employees, For more information, call the Oregon Employment Department at 503.947-1488.'
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The Oregon' Business Identification, Number (BIN) is a combil)ed:. !,lumber fQr,c both Of"gon o/ii~holding anf
Unemployment Insurance Tax, To file for a BIN, call 503-945-8091 or www.dor.state.or.us/fonnsnav.htmll for the
appro'p?ate,~or::ns'-,_ __ , c_ ;',"', "'." :'\'~ "
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Workers; Compensation Insurance: As an ,employer, 'you' are ~ubject to the Oregon Workers' Compensation Law,
. and ml.!.s!,ol>!~tl). wor!<:ers: for,npensation iJ1s~nceJ?ryol'r emp!oy~es, If you fail t() obtain. workers: compeqsation
insurance', you coultl tie' kuoject to\;eriafties'art.d'beliable I fof~l1 cla'im cO'shi If on~ of your emploYees' is\nj~ed on thb
job. For niore infomiation, call the Workers' Compe;satfon r:hvisioh at'the 'BeiialjnieritofCori'su'mer-aiid Busjnes~
Services at 503-947-7815. ." '
U.S. Internal Revenue SerVice: As an employer, you ~ust v..:ithhomtfedeiaJ 'income tax' from employees' -wag'"s j, ,
You win be liable for the tax payment even if you di(in't actually wiJhhold the tax, For a Federal EIN number, call th"
JRS,at 1~80'O-829'4!i3'3 orvisittheir;website'at:www.irgggy:;.'", ::I(',"'~'; ,;.' .:"t:~...".,,'. '" '.,:, , " '
,...;.~.r_:...:..-" "~;':"l:'-:'i '{1:'-:'. :.,..:',-"'-".'1:,:ir-:",', :: ....: ;"... ',H"" " .~',- .~';.i _ '.:~-,"~
~.'~ ;', :;r.t~. ,:';r.@therRespo.I,1&H)mtjes.~~!i Ar,~~s of Co~~ems:; ,,- " ','" ",:
Code Compliance: A~ the, P, erinft holder forthisproject, you are responsible for r~~OIVihg, airy failure'to ITieet COdj
reqUlrepe?ts ~hat may be brou~t to, your attentIOn through msp~~tlOns, . " " "
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Liability and Property DaIrllige in~tirance:' tOftta'ctYourtnsul'ahce agent tos~e'if yoid1ave 'ad~quate instfrancc
coverage for accidents and omissions sucIias falling tools, paint over spray, water damage from pipe punctures, frre,Ol
work that must,be redone, .-
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Time: Make sure'you,hilVe sufficient time to supervise your employees, '1!1 . ,;' \;',
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Expertise: Make sure YOll have the skills.to act as your own general contractor; to 'coori:linate the work of rough-in
and tinish 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 (503-378-4621) or write the agency at PO
Box 14140, Salerp, OR 97309.5052,
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Property_owner.doc 06-()J':04
225 Fifth Street
Sp,:ingfield,Oregon?7477
54]-7~6-3759 Ph.one"
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Job/Journal Number
COM2009-0 1487
COM2009-0 1487
COM2009.01487
COM2009.01487
Payments:
Type of Payment
Check
cReceintJ
. RECEIPT #:
City of Springfield Official Receipt
Development Services Department
Public Works Department
220090000000000]]58
Date: ] 0/0812009
Description
, Add, Alter, Extend Circ
Add, Alter, Extend Circ Ea Add
+ 5% Technology Fee
';t 12% State Surcharge
. ~ .
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"Paid'By';"
JOYCE PIERSON
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
CJc 2294 In Person
Payment Total:
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Page I of I
1I:55:53AM
Amount Due
55.00
18.00
3.65
8.76
$85.41
Amount Paid
, $85.41
$85,41
10/8/2009