HomeMy WebLinkAboutPermit Electrical 2009-12-3
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Date
ZON
INITIALS
DATE'
SOURCE
225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(S4I)726-3753 . FAX: (541)726-3689'
ELECTRICAL PENfIT APPLICATION
City Job Number (,(-l,- ()/1'd ~ 1
1. ILOgTIQMQJimSTAf:IfAfliJJV: ~
3::>7/ c Jas j)~v ,?)~.
f -
LEG\Yl)r~14 D~CO
..--'
JO WDE SCRIPTIO.;g
.,/; _v
j/J n ' /l.. ,[3,/
~'(/':J"'" I _~J...jCAc)
Pe~mits a~e Don-transferable and expire if work is
not started within 180 days of issuance or if work is
Suspended for 180 days.
3. f CO~PLEr.liFEE!i.GitEiJ~fBEi.11W
-,,1
A. b~~"wR~sid:'!t.i~I~SirigleorMijliHia'ffiiiy P!i-.iiwell'i~g.unii" I
Service Included
1000 sq. ft. or less
Each additional 500 sq. ft. or
portion thereof
Each Manufact'd Home or
Modular Dwelling Service or
Feeder
$117.00
$ 21.00
$55.00
2. ~;J'P~~ctQ!l:IN~.t4LqrroN",(}~t;~ B. ~,~tii~~..0~];~lJ!~iJ~~,tall~~~';,Alt~ta!i.o~~,"~~~eLo~~1j~n:.,J
Electrical Contractor J36f(j h '7;" e.v- Elt/:...-rIZIC- 200 Amps or less $70.00
201 Amps to 400 Amps $ 83.00
Address /9;1) roC/1/'{.'- /11A.ol( fJv-<...- 401 Amps to 600 Amps $138.00
60 I Amps to 1000 Amps $180.00
City fi'r''1-ll.....c Phone /9;;'1'7173 Over 1000 AmpsNolts $413.00
r ~ b'i5'1 (po t( [.. Reconnect Only $ 55.00
Supervisor License Number '7 c; ?c:;- 5 C. 1''i;;'Dlpo;'';,.y;~;-rVi~Cs,orF~~(Je.fi,
Expiration Dat~ If') - \ 0 _ r t> Installation, Alteration or Relocation ~3 _ ~
200 Amps or less ~ ~,OO---
Constr. Contr. NUJflber '91, "2. 7 '" 201 Amps to 400 Amps $ 76.00
401 Amps to 600 Amps $110.00
Expiration Date } ()- 10 - D '7- j/ /0/1 ()
. Over 600 Amps or 1000 Volts see "B" above.
Signature ofSEpervising Electrician D. t'Bfa~ch''CiI'cuiiS'"l';~:l1"
,-: -- i.! &ff J 1~ ~::;~:::tionorExtensionp~rp~~:,I'IO $48.00
- " Each Adm~r~if5\',it:!ll'lWi\flU\f"~~ Ufllity
Owners Nami-S/-I GU?ON /?1AS ON :;r~~S~n~~:~~r~X~~r~j;~:~~r 4.0:,++ "+'''! 1
Address 3:;r7t \.....,'as fUY ...e..J;J Jt.l9!'~H '96!~~(f\~,.&'(~~gZ!;;\l.'!ti'!~IUcf!!(t)'!:.EaCljl~stallatI~n1
NOTtr'/:. In OAR may obta\~. 'he t9',8;;""""
CIty ~ I/J;;t..--- Phone ~8JPlffl&'l!lWXer. (NO\~ii\iW "nliiicati()\$ 55.00
. HIS';fc~fT SHALL EXPIRE IF THE WORK S3'btHli~rlt!llbtQg:~g~_332-2~"'4). $ 55.00
OW~~Rr.NS.'f.AI!i!~ffoN-/'S PERMIT IS NOT Limited 1ll~\!\;iaentiiIl $ 28.00
!h;;~:t~fiMI6~.~s.9r~W1age~~l['p?&jJeHyf(lJWn which Limited EnergylCommercial $ 50.00
IS not Intended for sale,li'ease or rent Minimum Electric Permit Inspection Fee is $50.00 + Surcharges
. OWners Signature: 1\.01 -~ '" 4.ltSrJii'FOTAE+OFABO.VE.';'.'if;;:,;), I / S lfU
\,~~~_~\) ~"--' " ......-.. "+++'''+'-'~''-'''.j, lo '7' .
\,,:t(' \{}.\J$;\'O ~ :~~~~:i~::;::,~eFee --/. ~ ~
5% Technology Fee
~~~~:~:i'?~~;.:~ TOTAL :/t7.3 . f I
'J' \!d~' .::~ ~ '~~"""""",",'-- -"";~. ,~~
225 F "th Strcet
Spri"fi~IQ, Oregon 97477
541-726-3759 Phone
Wi:~
City of Springfield Official Rece\,t
Development Services Departmcnt
Public Works Department
Job/Journal Number
COM2009-0 1722
COM2009-0 1722
COM2009-0 1722
Payments:
Type of Payment
CreditCard
cRcceint I
RECEIPT #:
Date: 12/03/2009
2200900000000001347
[
Temp Power 200 amps or less
+ 5% Technology Fee
+ 1,2% State Sc. .1... 6'.
Paid By
Bud r l';:"nCI\' ELECI K.)L
CheCk N,imber
Received By Batch Number
Item Total:
AuthorizatIOn
Number How Received
130855 In Person
Payment Total:
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I ,~ D
( /\J G 7 C/
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L~~1JYU r--t
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//
Page I of I
10:35:20AM
Amount Due
63.00
3.15
7.56
)IJ./1
Amount Paid
$13.7/
"Jll["
12/3/2009