HomeMy WebLinkAboutPermit Electrical 2009-12-28
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Electricai Permit AppL ,tion
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225 Fifth Street. Springfield, OR 97477.PH(541)726-3753+FAX(541)726-3689
Date: 11 ~~ f' -.0 '?
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 is suspended for 180 days.
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j Residential, per unit, service include'd: I
o Residential I 0 Government 1 []}Commercial
~JOB.!lSlltE~It;.lF.:~[Ml,\if~ONlf~N!'>JJ!(;H::'J,I.i]j10N~!f4'1 11.000 sq, ft. or less (4) $134.00 $ I
1 I , I I Each additional 500 sq. ft. or portion $ I
J~b site ad~ess~ /::13 _ d. ,,,+er',,'<i-l< iCJ ,^-:,J luJ d Y thereof $ 25.00
: ~~:~i:~::,~~1~5)~te: 0 RJ Lo~::.P:6~ 76L I ~~:~t:;~~:~;~~homeormodular $ 32.00 $ I
1~'Bi~"iES.GRIE!m!~~!l1Qf~W~.~gs~~ dwelling service or feeder (2) , $ 63.00 $
1 1 J I [Services or feeders: installation, alteration, relocation I
7J Do.4-C(" r...", cr It.
1~~~~BPR~RiIi'i':~0W~I:R~~~~;.JI ~:~::~oo:::;:~ 1. : ::::: :J9rldJi 1'10
I Name: e\!.o.J... 14.~a"J'" I 1401t0600amps(2)l $158.00 $~I~." 'JIb
1 Add -... I I . I 1 601 to 1,000 amps (2) $205.00 $
ress: 1.2." I' 01) ;- e,.. ;J'i +-, f) ..., , ,) a. 1/
1 City: >P r " ., r- f.. e I J 1 State: D k I ZIP: lOver 1,000 amps or volts (2) $469.00 $
1 Phone: _./. ')23 -f>'i$' "r I Fax: 1 Reconnect only (2) ,$ 63.00 $
. I E.:.mail: I Temporary services ~.r,fe;ders: installation, alteration, relocation .1
, This installation is being made on residential or fann property I 200 amps or less (2) $ 63.00 $
owned by me or a member of my immediate family. This 1 201 to 400 amps (2) $ 87.00 $
property is not intended for sale, exchange, lease, or rent. OAR 1 ' 1 1
479.540(1) and 479.560(1). "'~' 401 to 600 amps (2) $126.00 $
Signature: , !ol/O"" '::!ON: Orer 0 Over 600 amps or 1,000 volts, see services or feeders section above 1
1~~'lllllirCl;)Nm@:GjnQa.lINSmiKl!l2'A'J1. $flit.'~!;'~\'(9P;' I its: new, alteration, extension per panel 1
I Business name: 0 hsoyt "IiI1~. ~J; SIl ~~ its with purchase of a service or feeder fee: 1
I Address: I~ ICJ LaJ!.,., Stve.e -l 'YObtall1c _.lI"f<6J1i:w.~1l4 . Iz",ol $ 6.001 $17,/001 17t.{0
1 City: ~_''v'BCJ,'';'l~ 1 State: oir..... , . ~IQ ."'tGlttttf,J J. its without purchase ofaservice orfeede;fee: 1
I Phone:-'5'i/ -Nr /11./foDI Fax:9-1/-7'll. <..J ,~ 1 Ii _.' u!t'(2) I $ 55,00 $ I
I E.mail: ~,l ~ranch circuit $ 5.00 $ I
1 CCB license no.: /",<'4 7'<. I BCD license no.: J(J ~Z l.{ l(~ 1 I Miscellaneous fees: service or feeder not included 1
I Signing supervisor's license no.: ~~-3 9$' 'I ,I Each pump or irrigation circle (2) , I $ 63.00 I $
I Print name of'signing supervisor: ~~M /./#I'( 1 Each sign or outline lighting (2) I $ 63.00 1 $
I Signature of signing supervisor: .,~" I Signal circuit or a limited.energy panel, I I $ 63.00 I $
, ,~ /?- alteration, or extenSIon (2)
---
I Each additional inspection: (I) I I $58.00 I $
_oJ.'. ~ ~'Y. 8' 1m:~~~J?[Il[i::ANJ~Q:sy;.~~m
y ;~.. ~~~ I (A) Enter subtotal of above fees
It> \. NOTICE: \, (Minimum Permit Fee $58.00) $ 2.1 'Ib" 22.llb
((S \,};,,,- THISPERMIT ., 'o1';:"'Yk'f. I (B)EnterI2%surcharge(.12x[A]) $w,P-1Z67Sl.
\~ ' ~UTHORI2EDJ:ALLfXPIFIEIFT '.' I (C)Technology Fee (5% of [A]) $'IIZY 1/lz:1D
, ANOMMENCED ORDER THIS PERM HE WOR"' TOTAL fees and surcharges (A through C): $ ~,j,..
Y 1 IS IT IS 'I un. "'?cx.. 70,.
. 80 DAY PE' R ABANDONED NOT ' 0:>
100. FOR ,,'
440-2584-) (9108ICOM)
225 Fifth'Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2009-0 1260
COM2009-0 1260
COM2009-0 1260
COM2009-0 1260
COM2009-0 1260
Payments:
Type of Payment
Check
cReceintl
~PJ:Q~:~
a"""
City of Springfield Official Receipt
Development Services Department
Public Works Department
RECEIPT #:
1200900000000001361
Date: 12/28/2009
Description
Penn Serv/Fdr 20 I to 400 amps
Penn Serv/Fdr 40 I to 600 amps
Add, Alter, Extend Circ Ea Add ,.'
+ 5% Technology Fee
+ 12% State Surcharge
Paid By
GLENDA KOOPS
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
1224
djb
In Person
Payment Total:
Page I of I
1O:32:17AM
Amount Due
190,00
316.00
1,740.00
112,30
269.52
$2,627.82
Amount Paid
$2,627,82
$2,627.82
12/28/2009