HomeMy WebLinkAboutPermit Electrical 2009-11-13
EIJdiical Permit Application
225 Filth Street.Spdngfield, OR 9747HPH(541)726-375HFAX(541)726-3689
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This permit is issued nnder 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.
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I Zoning approval verified? 0 Yes 0 No I I:N;'.ri'beti~fi~i~~~ii~;;;Ci:;~~rir~::;'();:rIQi/] ";$O~!!!;:I:;'fotal::1
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1~'il\f:i"'tl013j(SI'fE'HNF;QRMAT.fQIIlWf\IIl[j'm0C'AiJ!10N"1,-l'!':"I"'1 11,000 sq, It or less (4) $134,00 $ I
I';: ;~'te ad:ess: 'nry z 't' , , '. "...,p." I ~~~~:ritionaI500 sq ft or portion $ 25,00 $ I
I City: 51fJ r I f1 q p J-e. (0 I State: I ZIP, r 1<171 I Limited energy (2) , $ 32.00' $ I
I Referente: 170nbzJ I Taxlot.: 017"3' I Each manufactured home or modular $ 63.00 $ I
DESCRIP:n0N"r0F:.wORK,1\';';9;i,i:'{",;@'Y";:',~j dwelling service or feeder (2)
J Bf'!fnC-h c.L6+- A DY.] ,(:{,(' I I Services or feeders: installation, alteratian, relacation I
N-'f.~- I ' I 200 amps or less (2) $ 81.00 $ I
I ' , 'PROPERH': 'OWNER .. ",I I 20 I to 400 amps (2) $ 95,00 $ I
I Name LlflcJ{..L (f)~r-n ' I J401~~\~~J~- , $158,00 $ I
I Address: l:s tJ 2. e _ <>.('00 lac I ~'t'rWa~ ~~ $205.00 $ I
I City: SI){'llIq f'tt,rO I State:Or J4H':?W51.;<;l~O'l~\l\eIt'~~tS(2) $469.00$ I
I Phone: _ -' I Fax: '. ~ (.11"'" ~ 0Vl1. ~:~ I~~~~_ ' , $ 63,00 $ I
, ..... ee -f\-\ \. 0\'0'" ,,~.wiI) .
I E-mail' ',\i,v<-"';:"2._0cn-v' ~ i0P<jl.m,~~l p.rrfeeders: ,"stallatlOn, alteratIOn, relacal/an I
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This mstallatlOn IS being made on residentiali6\r'f,;rm'jlllwe~e0\~1' 'U""~ r (2) : $ 63.00 $
owned by me or a member of my immediate f\liiliIY~~lg~e ~0 gl0 ~ 0 amps (2) $ 87.00 $1
property is not intended for sale, exchange, lease~ lfl'l/l \gl,\ I\{' \ I I
479,540(1) and 479,560(1), (\\lll'l vel'i 401 to 600 amps (2) $126.00 $
Signature: . lOver 600 amps or 1,000 volts, see services or feeders section above I
I, ,', ,':;:"CON'fRACl'OR"INS-Cf\tLA5J0N:"',,,' ", ,[ I' Br_~nch circuits: new, alleration, extension per panel 'I
I Business name: C-A 1\/f\.lri1\J ~J..t!uiiRA.I' I I 'a~ Fee for branch circuits with purchase ofa service or feeder fee: I
I Address: _ fn Cl.-:t-,t::;' , _ ,~ "I I Each branch circuit I I $ 6,00 I $ I
City: (~"-::-ffl1 StaIDR I z{pf Hil1-'1 rb Fee for branch Circ,Uits without purchase ofaservice or feeder fee: J
Phone, 7)j~O&-' S - I I Fax' - 61O~, First branch circuit(2) '1'''1' I $ 55,00 I $ S~ I
E-mail, , , I I Each additional branch circuit I' $ , 6.00 $?z..
CCB license no" ;;z.O~ 30'2- <[.sCD license no,: -; (0 jO'{ I I Miscellaneous fees: serviceq!.f.~~c!eri'ho(incl~ded
Slgnmg supervisor's license no 5i1 l1 ~ ,) I I Each pump or Irrigation Circle $ 63.00
Print name of signing supervisort A) _ X)~~~h ~~I",_l ~ _ 1 $ 63.00
Signature of signing supervIsor / ;J A<<:?.~ ~ pf,i~j:J.i't\.~"t~~~ ' , " $ 63.00 $
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,("\~ . MY .--0.. ~~;~~e:~!>~A.'tion:,~)._", ,,$5,B'~~"'~""'>')1
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. I TOTAL fees and surcharges (A through C): $ 7/ :J I (
$
$
440-2584-) (9/08/COM)