HomeMy WebLinkAboutPermit Electrical 2004-2-5 (2)
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225 FIFTH STREET. SPRINGFIELD, OR 97477 · PH:(541)726-3753 · FAX: (541)726-3689
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ELECTRICAL PERMIT APPLICATION I' . a-,?-ot
( 5 / . Date .
City Job Number CDW1 Z 004 _ 601 0 b Date '2 /0 Lf ., cKvJ
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Installation, Alteration or Relocation
200 Amps or less
NOTICE: 201 Amp's ~v1Q~"HE WORY. $ 69.00
THIS PERM'40~N R 1~~ mMIT 's NOT $100.00..
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ANY 180 1\V".'", "'ili~~,,,,"'F~.~+. . ""Y!~'i'''\~''~'''''''' ,~; ~""-<""'" "',',
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New Alteration or Extension Per Panel
One Circuit j
Each Additional Circuit or with ($ 3.00
Service or Feeder Permit
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LEGAL DESCRIPTION
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JOB DESCRIPTION
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Permits are non-transferable and expire if work is
not started within 180 days of issuance or if work is
Suspended for 180 days.
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Electrical Contractor
Address
City
Phone
Supervisor License Number I ~ II- /
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Expiration Date
Constr. Contr. Number
,
Expiration Date
Signature of Supervising Electrician
Owners Name ch;~{ E<;.
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Address
City
Phone
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OWNER INST ALLA nON
The installation is being made on property I own which
is not intended for sale, lease or rent.
Owners Signature:
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Inspection Request: 726-3769
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Service Included
1 000 sq. ft. or less
Each additional 500 sq" ft. or
portion thereof
"..
$106.00
$ 19.00
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Each Manufact'd Home or
Modular Dwelling Service or
Feeder
$50.00
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200 Amps or less
20 I Amps to 400 Amps
401 Amps to 600 Amps
60 I Amps to 1000 Amps
Over 1000 AmpsN olts
Reconnect Only
$ 63.00
$ 75.00
$125.00
$163.00
$375.00
$ 50.00
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. $ 50.00
$ 43.00
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'sc'ellaneoiis;(Ser.:viri1'lfeede'if\jrof~tiiCluded)<::Each:lnstaLii\ tioilii~
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Pump or irrigation $ 50.00
Sign/Outline Lighting $ 50.00
. Limited EnergylResidential qu roo you +^$ 25.00
ATTttNT~:ur~pon la~ re I ~
followUVUfes Rffa~tt:lo~\q\~ Ore~nn Iltilit~$ 45.00
. M\Wm-Mllbf:}~t!";~nfrijijtcJnspedi()il E1e€liSl$.Hmo~ + Surcharges
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ca~~~ta~eSienter. (Note: the telephone
nU"lher tfO~ tM~~~gon Utility Notification
D%,A<;lD1imstI;a~Y~(liAl';;~32.2344). .
TOTAL
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Shared Drive(T:)lBuilding Fonns/Electrical Permit Application I-03.doc
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. CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2004-00106
ISSUED: 01126/2004
APPLIED: 01126/2004
EXPIRES: 08/05/2004
VALUE:
. Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 4675 DAISY ST
ASSESSOR'S PARCEL NO.: 1702324308101
Springfield TYPE OF WORK: Heating System
TYPE OF USE:
Addition
Residential
PROJECT DESCRIPTION: Add heat pump and coil
Owner: ROBERTSON CHARLES A TE
Address: 4675 DAISY SPRINGFIELD OR 97477
I CONTRACTOR INFORMATION.
Contractor Type
Electrical
Mechanical
Contractor License
OWNER
ASSOCIATED HEATING & AIR CONDITIO 106275
I BUILDING INFORMATION I
Expiration Date Phone
08/31/2004 541-683-2590
# 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:
Lot Size:
Sq Ft 1st Floor:
Sq Ft 2nd Floor:
Sq Ft Basement:
Sq Ft Garage/Carport
Sq Ft Other:
Impervious Surface Area:
SETBACKS
I DEVELOPMENT IN FORMA TION .
Frontyard Setback:
Side 1 Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Overlay Dist:
# Street Trees Rqd:
Paved Drive Rqd:
% of Lot Coverage:
REQUIRED PARKING
Total:
Handicapped:
Compact:
I PUBLIC IMPROVEMENTS I
Street Improvements:
Storm Sewer Available:
Special Instruction:
NOTICE: .
Notes: THIS PERMIT SHALL EXPIRE IF THE WORK
AUTHORIZED UNDER THIS PERMIT IS NOT
COMMENCED OR IS ABANDONED fOR
ANY 180 DAY PERIOD.
Sidewalk Type:
. 'TTENTIBf-r.'e1PJl~bVP.E.~s:)qUlres yoU. ~o
A I I b the Oregon Utility
follow rules adopted ~e rules are set fort
\Jotification Center. Tho hOAR 952-00
R 952-001-00~ Q thro~g
n OA ." obtain' copies of the rules \
0090. :ou may t (Note: the telephone
call1ngtfhetChen ;:~gon Utility Notification
number or e 44)
,....-:-"'+~.. ic:: 1_ROO-332-23 .
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Pal!:e 1 of3
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. CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2004-00106
ISSUED: 01/26/2004
APPLIED: 01/26/2004
EXPIRES: 08/05/2004
VALUE:
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
I Valuation Description I
Description
Tvpe of Construction
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Value
Date Calculated
Total Value of Project
~ .'
Fee Description Amount Paid Date Paid Receipt Number
-Mechanical Issuance Fee- $10.00 1/26/04 1200400000000000109
+ 10% Administrative Fee $4.50 1/26/04 1200400000000000109
+ 7% State Surcharge $3.15 1/26/04 1200400000000000109
Miscellaneous Mechanical $45.00 1/26/04 1200400000000000109
+ 10% Administrative Fee $4.60 .215/04 1200400000000000166
+ 7% State Surcharge $3.22 2/5/04 1200400000000000166
Add, Alter, Extend Circ $43.00 2/5/04 1200400000000000166
Add, Alter, Extend Circ Ea Add $3.00 2/5/04 1200400000000000166
Total Amount Paid $116.47
I Plan Reviews I
To Request an inspection call the 24 hour recording at 726-3769. All inspection requested before 7:00 a.m.
will be made the same working day, inspections requested after 7:00 a.m. will be made the following work
day.
2 Rough Mechanical: Prior to Cover
1 Final Mechanical: When all mechanical work is complete.
3 Rough Electric: Prior to Cover
4 Final Electric: When all electrical work is complete.
Paee 2 of3
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~
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Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
.
. CITY OF SPRINGFIELD'
Building/Combination Permit
PERMIT NO: COM2004-00106
ISSUED: 01/26/2004
APPLIED: 01/26/2004
EXPIRES: 08/05/2004
VALUE:
By signature, I state and agree, that I have carefully examined the completed application and do hereby certify that all
information hereon is true and correct, and I further certify that any and all work performed shall be done in accordance with
the Ordinances of the City of Springfield and the Laws of the State 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.
I further certify that only contractors and employees who are in compliance with ORS 701.005 will be used on this project.
I 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
times during construction.
Owner or Contractors Signature
Pal!e 3 of 3
Date
.
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.oVVl zc. - 00 lOG:.
Issued by:
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Date: zj ~A I..{
Address:
Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701.055(4) requires residential construction permit applicants who are not
licensed with the Construction Contractors Board to sign the following statement before a building
permit can be issued. This statement is required for residential building, electrical, mechanical and
plumbing permits. Licensed architect and engineer applicants, exempt from licensing under
ORS 701.010(7), need not submit this statement. This statement will be filed with the permit.
Fill in the appropriate blanks and initial boxes 1 and 2, and either box 3A or 3B:
~1.
~2.
I own, reside in, or will reside in the completed structure.
I understand that I must become licensed as a construction contractor if the structure is sold or
offered for sale before or on completion.
o 3A. My general contractor is
(Name)
(CCB #)
I will instruct my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
OR
~ 3B. I will be my own general contractor.
If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract with a contractor who is
licensed with the 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 the Information
Notice to Property Owners about Construction Responsibilities on the reverse side of this form.
(l ~ a- p~ ~-.j-- ~ 7'
(Signature of permit applicant) (Date)
(White copy to issuing agency permit file, pink copy to applicant.)
Property_owner. doc 03/11/03
. .
A~ting asY our. Own General Contractor?
INFORMATION NOTICE TO PROPERTY OWNERS
ABOUT CONSTRUCTION RESPONSIBILITIES
.,.,
NOTE: This Information Notice to Property Owners about Construction Responsibilities was developed by the
Cqnstruction Contractors Board in accordance with ORS 701..055(5), passed by the 1989 Oregon Legislature.
If you are acting as your own contractor to construct a new home or make a substantial improvement to an existing
structure, you can prevent many problems by being aware of the following responsibilities and concerns.
Employer Responsibilities
You will, in most instances, be ruled to be an "employer" and the contractors you contract with will be "employees" if
you use contra.ctorsnot licensed with the Construction Contractors Board to .do labor in constructing or to assist in the
construction or improvement ofa res.idential structure. As the employer, you must comply with the following:
Oregon's Withholding Tax Law: As an employer, you must withhold income taxes from employee .wages at the time
employees are paid. You will be liable for the tax payments even if you don't actually withhold the tax from your
employees. For a State Business ID number, call the Business Information C~nter at 503-986-2200. .
. .
Unemployment Insurance Tax: As an employer, you are required to pay a tax for unemployment insurance purposes
on the wages of all employees. For more information, cali the Oregon Employment Department at 503-947-1488.
Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law,
and must obtain workers' compensation insurance for your employees. If you fail to obtain workers' compensation
insurance, you could be subject to penalties and be liable.for all claim costs if one of your employees is injured on the
job. For more information, call the Workers' Compensation Division at the Department of Consumer and Business
Services at 503-947-7815.
U.S. Internal Revenue Service: As an employer, you must withhold federal income tax from employees' wages.
You will be liable for the tax payment even if you didn't actually withhold the tax. For a Federal ElN number, call the
IRS at 866-816-2065 or fax them at 801-620-7115. .
. . Other Responsibilitie~ and Areas of Concerns
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. .
Liability and Property Damage Insurance: Contact your insurance agent to see if 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. ' ..
Time: Make sureyou have sufflcienttime to supervise your employees.
'.. . .
Expertise: Make sure you have the skills to act as your own general contractor, to coordinate the work, of rough-in
and finish trades,"and to notify building officials as the appropriate times so they Cal1 perfonn the required inspectIons.
If you have additional questions call the Construction Contractors Board (503-378-4621) or write the agency at PO
Box 14140, Salem, OR 97309-5052.
Property_owner.doc 03/11/03
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
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City of Springfield Offi'Cial Receipt
.'
Development Services Department .
Public Works Department -
Receipt #: 1200400000000000166
Date: 02/05/2004
lO:29:16AM
Job/Journal Number
COM2004-00106
COM2004-00 1 06
COM2004-00 106
C0M2004-00 1 06
Description
+ 7% State Surcharge
+ 10% Administrative Fee
Add, Alter, Extend Circ
Add, Alter, Extend Circ Ea Add
Amount Paid
Item Total:
3.22
4.60
43.00
3.00
$53.82
Payments:
Type of Payment
Cash
Paid By
CHARLES ROBERTSON
Received By
djb
Check Number
Batch Number Authorization Number
How Received
In Person
Payment Total:
Amount Paid
$53.82
$53.82
.
.
.