HomeMy WebLinkAboutPermit Electrical 2010-2-11
Electrical Permit Application
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225 fifth StreettSp.-ingfield, OR 97477.PH(541)726-3753.FAX(541)726~3689
1'~;',;T,6.~~~Rl~E-NfO~'E, ONLY;,.:, I
I Permit no. C/O ~ j? I I
I Date d/I///() , I
This permit is issued under OAR 918-309-0000, Permits are nontransferahle. Permits expire if work is not started within 180
days of issuance or if work is suspended fnr 180 days,
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I Job site address: fOr;2.. C Ie 4.fI.- wit.. fe;.... L.o"n "- . I
1 City: 5!'/l-/'? J~'eM I State: C//.._ I ZIP: 'll"'p'3t/ I
I Reference: \9-K) he:; 2..4\ I Taxlotfftl'U::C) I
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;PROPERTV;,OVVNER' '..:.
[ Name SI-CGi?n (I)/l ne/,/;j
I Address: d--b D (A'l.VtJ, <'It.
I City: ZVfic'i"<- 1 State: OIL 1 ZIP: 77'/01/
I Phone:S-1N ~''I'I )'j'ir) I Fax:
I E-mail:
This installation is being made on residential or farm property
owned by me or a member of my immediale family. This
property is not intended for sale, exchange, lease, or rent OAR
479.540(1) an 9.5 1).
Signature: ~
, ,': '.. :'CONfRACTOR;' INSTALLA'fIc:1N:"
I
I Business name:
1 Address:
1 City:.............
I Phone: -~
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1 Stale:' jriiP:
I Fax/
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CCB license no.: . ~BCD Iic~_
I Signing supervisor's Iic.>~ no,:
I Print name ofsign~upervisor:
I Signature .5J.f:.~ing supervisor:
E-mail:
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440-2584-J (9108/COM)
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,Nurnberofms ectlOnSi er.ltern" ': '!k~' ,t. ~'l'-''-' '..,<" \: c" -,,", '...:
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1 Residential, per unit, service includ;ed: $r~
I 1,000 sq. ft. or less (4) I $134.00
I Each additional 500 sq. ft, or portion l. $ 2S.00 $ rofL/
thereof
I Limited energy (2) $ 32.00 $ I
I Each manufactured home or modular $ 63.00 $
dwelling service or feeder (2) .
I Services or feeders: installation, alteration, relocation
1 200 amps or less (2) $ 81.00 $
1 201 to 400 amps (2) $ 95.00 $
1401 to 600 amps (2) $158.00 $
601 to 1,000 amps (2) $205.00 $
Over 1,000 amps or volts (2) $469.00 $
Reconnect only (2) $ 63.00 $
Temporary services or feeders: inst~llation, alteration, relocation
200 amps or less (2) I $ 63,00 $
I 201 to 400 amps (2) I $ 87.00 $
I 401 to 600 amps (2) 1 $126.00 $
lOver 600 amps or 1,000 volts, see ser~ices or feeders section above
1 Bra~ch circuits: new, alteration. ext~"nsion per panel
I I. a. Fee for branch circuits with purchase of a service or feeder fee;
I I ' Each branch circuit I $ 6.00 I $
1 ,I b, Fee for branch circuits without purchase of a service or feeder fee:
I First branch circuit (2) I I $ 55.00 I $
I Each additional branch circuit $ 6.00 $
I 1 Miscellaneous fees: service or fteder',!ot included
1 I Each pump or irrigation circle (2) I $ 63.00 $
I I' Each s;gn or outline lighting (2) $ 63.00 $
I I Signal circui,t or a limited~energy panel, $ 63.00 $
alteration, or extension (2)
1 Each additional inspect;on: (I) I $58.00 $
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l~'1'~":~$~"0Ji~+~t2::Y+$&~Jttil~,, "r;.liL _. . ~I',:.~_U_. \~,~I1ifi.1~;f,j~;fM&foil~~~1;VUt.,,',.i';:
(A) Enter subtotal of above fees
(Minimum Permit Fee $58.00)
.1 (B) Enter 12% surcharge (.12 x [AD
1 (C) Technology Fee (5% of [AD
1 TOTAL fees and surcharges.(A t!trough C):
$ left!;, 00
$ ;}?--~ O~
$ q" J10
$ 2 J-5:I?g'
CITY VI' ~PRINGFIELD
Building/Combination Permit
L'
Status
Issued
,
PERMIT NO: COM2010-00191
ISSUED: 02/11/2010
APPLIED: 02/11/2010
EXPIRES: 08/11/2010
VALUE: .
ZZ5 Fifth Streel,Springfield, {)R
54] -726-3753 Phone
54] -726-3676 Fax
54 ]-726..3769 Inspection Line
SITE ADDRESS: ]082 CLEARWATER LN
ASSESSOR'S PARCEL NO.: ]802052408200
Springfield TYPE OFWORK: Electrical Work Only
TYPE OF USE: New
Public
PROJECT DESCRIPTION: House re..wire
Owner: MACDONALD DOUGLAS
Address: ]058 CLEARWATER LN
SPRINGFIELD OR 97478
I CONTRACTOR INFORMATION ,
Contractor Type
Electrical
Contractor
OWNER
License
Expiration Date Phone
. B~ILDING INFORMATION I
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
# of Stories:
Height of Structure
Type of Heat:
Water Type:
Range Type:
Energy Path:
Sprinkled Building:
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft GaragelCarport
Sq Ft Other:
Occupant Load:
nla
I DEVELOPMENT INFORMATION I
. REQUIRED PARKING
Front yard Setback:
Side I Setback:
Side Z Setback:
Rearyard Setback:
Solar Selbacks:
Overlay Dist: .
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
Total:
Handicapped:
. Compact:
I PU~L1C ]MPROVEMENTS I
Street Improvements:
Storm Sewer Available:'
Special Instruction:
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ATTENTION: Oregon law requires you to
. Sjl!f.U'~,Iltll!l!Beadopted by the Oregon Utility
6m.!)!ifn'l1i\lIJ/~~.nW, Those rules are setlorth
In {)AW'9'S':;qj'O 'fallJ1 0 through OAR 952-001-
0090. You may obtain copies 01 the rules by
calling the center. (Note: the telephone
number lor the Oregon Utility NotiflC8tiOll
I"'.o...+.ol";,e. 1_gf"l~_f,;J.I)?_"'2A,,\\
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Notes:
Description
NnTH~F'
THIS PERMIT SHALL ~^P.If\E If Trii; h6Rtt I
AUTHORIZED UNDER t;lf,lll~l:..".\~gQnintion
COMMENCED OR IS ABNJ,9Q~~P FOR Square Foolage
T~~ff1<8't1'rlJ\'f!lrRIOD",r multiplier or Bid Amount
Value
Date Calculated
Page] of 2
225 Fifth Street, Springfield, OR
541-726..3753 Phone
541..726..3676 Fax
541-726..3769 Inspection Line
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CITY OF SnUl~lJl' I.I!,LD
Building/Combination Permit
PERMIT NO: GOM2010-00191
ISSUED: 02/11/2010
APPLIED: 02/11/2010
EXPIRES: 08/1112010
VALUE:
Status
Issued
Total Value of Project
Fees Paid I
Fee Description
+ 12% State Surcharge
+ 5% Technology Fee
Residence Wiring 1000 Sq Ft
Residence Wiring Ea Addtl 500
Amount Paid
Date Paid
Receipt Number.
$22.08
$9.20
$134.00
$50.00.
2/11110
2/11110
2/11110
2/11110
3201000000000000044
3201000000000000044
3201000000000000044
3201000000000000044
Total Amount Paid
$215.28
I Plan Reviews I
To Request an inspection call the 24 hour re<<;.ordi!lg,at.726-3769. All inspections requested before 7:00
a.m. will be made the same working day, insp~ctions requested after 7:00 a.m. will, be made the following
work day. ."
Renuired Insnections .
Rongh Electric: Prior to Cover
Electric Service: Approval reqnired prior to utility company energizing service.
Final Electric: When all electrical work is complete.
By signature, 1 state and agree, that 1 have carefully examined the completed application and do hereby certify that all
information hereon is true and cOlTect, and 1 further certify that any and all work performed shall be done in accordance with
the Ordinances of tbe City of Springfield and the Laws of the St~te of Oregon pertaining to the work described herein; and
that NO OCCUPANCY will be made of any structure without permission of the Community Services Division, Building Safety.
1 further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project,
1 further agree to ensure that all required inspections 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 plans will remain on the site at all
';~;4--~
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Owner or Contractors Signature ' 'r>" '. / Date
Pa~e 2 of2
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM20 I 0-00 191
COM20 I 0-00 191
COM2010-00191'
COM20 I 0-00 191
Payments:
Type of Payment
Credit Card
cReccintl
RECEIPT #:
SP.,At.~Qr:I.~ii... :.'.
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..
'.' _"'M"""'~"""'~ " ..;
City of Springfield Official Receipt
Development Services Department
Public Works Department
3201000000000000044
Date: 02/1112010
Description
Residence Wiring 1000 Sq Ft
Residence Wiring Ea Addtl 500
+ 12% State Surcharge
+ 5% Technology Fee
Paid By
STEVEN R. CORNELIUS
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
nJm
359669
359669 In Person
Payment Total:
,;:,i
j; ~(~, :Jl I ~ .
Page I of I
2:17:37PM
Amount ~ue
134.00
50.00
22.08
9.20
$215,28
Amount Paid
$215.28
$215.28
2111/2010
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Construction Contractors Board
700 Summer St'NE Suite 300 .
PO Box 14140
Salem OR 97309-5052 -, .
Phone: 503-378-4621
Web Address: www.ccb.state.or.us
-
Permit #: C--/ O,-jq /
.Ad~~SS:/D:s:zrlj1/ ~#IAJ~--(Gy 6J
ISSU~.01/J 'Date:r:) 1;/ //0
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. Statement: Information'Notice to Property OWners
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About Construction Responsibilities
.1.
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'.
. Note: Or~gdn Law,.ORS 701.055 (4) requires residential constructio~ permit:applicants'who are not
, licenseiFwith the Construction Contractors Board. (0 sign the following statement before a building
permit can be issued. . This 'statement is requiredfor residential building, electrical, mechanical and.
, plumbing permits. Licensed architect and engineer applicants, exempt from licensing under' . .
ORS701,OJO(7), need not submit this statement, This statement will?e filed ~ith the permit, .
Fill in the appropriate blanks and ib.itia~ boxes,l and 2,/md either box 3A or 3B:
,
,.
. '~!
I;' I ~wn, reside in, or will reside in the completed structure. ;
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2: I understand that I must become licensed. as a construction contractor if the structure is sold or
'''offered for sale before or <in completiOli..
o 3A. My general contractor is
. (Name)
"
,
(CCB #)
-#'-' " . _ . \-'..' .....
I Will instruct my generai contract,or that all sub.contractors who work on tli~ structUre m~st be
licensed 'with the Construction Contractors Board, . . i . .
OR
IgJ
3B. I will be my own general cOJ}~actor.
If! hire subcontractors, I wili hire oniy subcoJ}tractors ILcensed with the Ccinstructio~ Contracto~s
Board. If! change my mind and hire a general cOl).tractor, I will contract with a contractor who is
licensed witJithe CCB and will immediately notify the office issuing this building permit of the
name of the contractor.'
I hereby certify that the above information is correct and that I have read and do understand tbe Information
Notice to Property Owners about Construction Responsibilities'on the reverse side 'of this form.. '
~ .
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(Signature of permit applicant) . (Date)
(Whitf! copy to issuing agency permit file, pink copy to applicant.) . '
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ProperlLowner.dilc 06..01..04
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'Acting a'$~)<:Qu!'t Own General.ContJrflctor'!f
,:. .~, ,,-'.\ ,... ' '_ ~\ .' .:_ '-y~;. , "" ,'f," .:. !f j"
;:'"",'~ . ->.- INFORMATION NOTICE'TO PROPERTY OWNERS:
, ABOUT,CONSTRUCTION:RESPONSIBILlTIES .,':
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NOTE: This Information Notice to Prpperty'Owners about Construction Responsibffities was developed by the
Construction Contractors Board in accordance with ORS 701,055(5), passed by the 1989 Oregon Legislature.
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If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing
, stnicture, you can prevent many problenis:bybeingaware of the follOwing responsibilities ,an9 concerns,
Employer Responsibilities
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You willi in most instances,.be.ruled to, be an."employer." and the.contractors you contract/with will :be, "employees" if
.' '.. _ .' .. .., _,. -, ~.t, .'.;.,.'.- ...'. ... ,-.. j ~ .' ' ,"'. \.~'''' ..., , .,.,
you:u~e c<'>PV.\l9!<,>~s,not,1icensed Wi!h,the,C?!1s~cfion contra~t?rs Board.t? do)~bor ip C\\P.ttr.uctingor t~ assi~t in the
construction~o.,r !.~p~o~~men~ <,Jf a resi(\~;ial,sj:rucl1!I'e':,A.,~the ~~Jllo~er, ypu must ~~,~~~ ~jththe !on~~in,g:
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.Oregon's Withholding Tax Law: As an employer, you must withhold income tax:es'froti1employee wages at the time
employees are paid. You will be liable for the tax payment~ even if you don't actually Withhold the tax from your
employees, For more infoITnation: 'tall the'Departmenf ofRevenweat 503..378-4988. '., ';':" - ';, - .
,
Unemployment Insurance Tax: As'anemployer, YOlHlre required to pay a tax'for UnempjoYment insurance purpose,s~,
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 Ide1)tification.,Number',(BIN) is"'a cOI1)bineq number;. f<,>r,Qoth. Oregon' Withh!>lding and .'
Unemployment Insurance Tax. T.o file for a BIN, call 503-945-8091 or www.doLstate.or.us/formsnav.htrnl1 for the
ap~r.opri::te.'fon:'s: i __ . _. __ _ __ _ .. ,,' ,:', ' . .. ,'!: i'. L~
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Workers' Compensation Insurance:,As an employer; you are subject to the Oregon Workers' Compensation Law,
and must..obtain workers' cqmpensation insurance for your employees, If you fail,to obtain workers' compensation
insuran6M, yoii'~ouia~e' sh~j~~{to i>'eiiald~s'arid lie liable. [bf all' daiin- cosfs' i'i' 6nli)fj6it '~liipi.oy'ee~ is injured on the
. ]ob,Foi moreiiiformation; call the Workers' Compensation DiVision at the;t:>'epartment':of C6nsumer arid Business
Services at 503-947..7815.
,,~ .
U.S. Internal Revenue Service: " As 'an employer, you must withhold federal 'mcometaX'from employees' wages~:
Y ouwill be liable. for the tax .payment even if you didn't actually wjthhold the tax. For a Federal EIN number, call the
IRSan~800'8294933 ,or visir-theirweb site at ,\"vw,irs gQ'\') ,', .:" . . ; -', ,.;,.. ,,';' _,,;,
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Code Compliance: As the' permit holder for this project, you are responsible for resolving any'failure to meet code
requirements that may be brought to your attention through inspections, ,-
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Liability andProjier'ty DlImage'I'nsul-ance:.- Contact 'YO~lr insurance '~gent 'to 'seeif you have adequate insurance .
coverage for accidents and .omissions such as falling tools, paint over'spray, water damage'from pipe punctures, fire or
work that must be redone. -::~ - . ". -.~ '." . -'~,_--
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Time: Make ,sure you have, sufficient time to supervise your employees,.. ,. , ,., ":. ;,. J ,.
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Expertise:. Make sure you have the skills to act' as' your own general confractor, to cO'ordinate'the work of rough..in
and finish trades, and to notify building officials as the appropriate times so they can perforin the required inspections.
,I
If you have additional questions call the Construction Contractors Board (503..378-4621) o~,write the agency atPO
Box 14140, Salem, OR 97309-5052. . I -
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Property- owneLdoc 06-0 h04