HomeMy WebLinkAboutPermit Electrical 2009-10-26
225 Fifth Street. Springfield, OR 97477. PH(541)726,3753. FAX(541)726,3689
I~:; DEFi,~RTMENT USE ONlY "I
I Permit no,: 0Po/ rVL- I
I.Date:.,\DlL\o J:f\",.,I,
ElecJricl:,l1 Permit Application
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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 \,s suspended for 180 days.
Signature:
I. ':CONTRAC'l'ORINsTALlATIC)N" '
I Business na~e: ()iZl'~\fY\','r;!ed~i', Qe~L\-PltiY\(.JI.
I Address' nrf-1 ,(,'y:::, {?~ PrDe..' I,
I City: '~~,tLl'V'\A I State: I'l!... 1 zlP1l214
I Phone:C:-J 17-, -2l?, 4 0l-/Jj) I Faxffi 2-~q {lYe, l
E-mail:S.o... \liV\<:' e,C)~CII)'\-dtC~(: {cW'\
CCB license no,: 2lJ" , I BCD license no,:
I Signing supervisor's 11ce';-sen'0,: 50S" S
I Print name of signing supervisor: :5'0"- 1(....l :O!-
I SignatureofSigningSupervisorq,~ -t(\. Lb
., "'l!O(;AL:'GOfJERNMENt:AF1PROVA"lli1';ii:~iW.:Yi;iX(';1 1;'1;!::;';!J~\'~'l71rr~~i#"(~EE~s(;I'lI:[jC!lEE!.\il~?il~I;!!\1(:~~'ii),'if;\\\'i'IL~
i,;O,~}~~. ~~i~;;~~~I~~~'{C)F'C~~~sRuct'()~"~~;",,, ,I 1:.~~~~~<6iAf~~~~ti?n};p'~:r;F~~:{~T;XI8F.I:;i,;~~~~} '1,;'~~t~I;,.1
I"~:_;~;:~'~~~t;al'" I ~"~o~:~~ent ' j' D c~:~er~ial I Residential, per un;4 service included: I
1~.),0.B~sJT:EllINF,~RMAffifOJiI::~Nll!ml!QGA;r,ION~~l!>,lgV 11,000 sq, ft or less (4) $134.00 $ 1
I' ,... '? vi'- \~t.b 4J c I ' I Each additional 500 sq ft or portion $ 25.00 $ I
Job sIte address: '::-J~) V\. I"N~ _ thereof
!,;!~~~:;,J;~:;::~~~~i i :;:~=~=;1;;~"'" :::: . I
I' . 'k;J 1:::0 ' vv ~'U \. < ',' ,-, "'" ,. \ I Services or feeders: installation, alteration, relocation I
1 I 1 200 amps or less (2) ~/I $ 81.00 $ 32'l I
I PROPERTY, OWNER I, 1 201 to 400 amps (2) 1 $ 95,00 $ 1
I Name: .LXtte _jU,."NIrlA VV\(D?- 1 I 401 to 600 amps (2) 1 $158.00 $ 1
I Address: <.i!.l"\tb\ 'Vm~(\ f1 e.dJ 1 I 601 to 1,000amps (2) 1 $205,00 $ 1
I City;nn~ '. r State:Ol-= 'I ZIP:~ 1 over/:()OO, amps or volts (2) , $~69,00 $ 1
1 Phone: ,:"'J- '-;" I FaX:,' "" 1 I,R"connectoEly(2),',~'; -;,' $ 63.00$' . ,I
IE-map:, . . (, 'j . , I I ,Temp~~~? se~vic'~s o~ f~eders: installation, a/ter~tion, r.e(6caiion I
Th" II " . b . d - 'd' I ", ' , I 200 amps or less (2)' ," , , $ 1 $ , I
IS msta atlOn IS emg ma eon reSI entIa or'larrn property , '_.~. . ' . ,~ r, 63.00 "
OWned by me or a member ormy immediate family, This I 201 to 400 amps (2) $ "87,00' $ I
property is not intended for sale, exchange, lease, or rent. OAR 1 ' I
479,540(1) and 479.560(1), 401 to 600 amps (2) '$126.00 $
I
I
I a, Fee for branch circuits with purchase of ~ service or- feeder fee: I
Each branch circuit Iloz-1 $ 6.00 1 $'C:>/'J., I
I b. Fee for branch circuits without purchase of a service or feeder fee: I
I First branch circuil (2) , I I I $ 55,00 I $ 55" I
" I Each additional branch circuit I' $ 6.00 $ I
I Miscellaneous fees: service or feeder ,:-ot included I
I Each pump or irrigation circle (2) $ 63,00 $ 1
1 Each sign or outline lighting (2) $ 63.00 $ I
I Signal. circuit or a li~ited-energy panel, I $ 63.00 $ I
alteration, or extenSIon (2)
,lEach additional inspection: (I) I' I $58.00, $, 1
. :tdR~;X\~...~~~~r1L/1~~~:-~~:~
'~\~ (\'I-ti)\.M.Jj,~~ .c5\..{<C) Technology Fee (5%of[AJ) $ 1,1'1.551
t)'-!'V ~ \.~, \, () ..p'~ ~ 1 TOTAL fees and surcharges (A through C): $ /, IS'? 'l2 I
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Over 600 amps or 1,000 volts, see services or feeders section above
Branch circl!its~ new, alteration, extension per panel
440-2584-1 (9/08/COM)
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone--,-,.
City of Springfield Official Receipt
Development Services Department
Public Works Department
Job/Journal Number'
C0M200S-00 172
COM200S-00 172
COM200S-00172
COM200S-00172
COM200S-00 172
Payments:
Type of Payment
CreditCard
cReceiotl
, RECEIPT#:
2200900000000001203
Date: 10/20/2009
Desc~ipti~n
Add, Alter, Extend Clrc
, ,Add,. Alter, Extend Clrc Ea Add
,"'" "'. " . '-'! ;
'Penn Serv/Fdr 200 amps or less
+ 5% Technology Fee .
+ 12% State Surcharge
Paid By -'
SHIRLEY A, LANS
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
nJrn
016340 In Person
Payment Total:
Page 1 of I
1:51:29PM
Amount Due
55,00
'612,00
324,00
49,55
IIS,92
$1,159.47
Amount Paid
$1,159.47
$1,159.47
10/20/2009