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Home My WebLink AboutPermit Electrical 2004-1-29 225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (5411l726-3689 b . d h h f II . 1 hE:-fO 16wmg project as su mltte as t e 0 oWing ELECTRICAL PERMIT APPLICATION 2"'''''9, and does not require specific land use City Job Number " Ccm a OVM - COo 7 0 Date 1/21 /tJ tf "wrova!. L 1'::::> VL- ~()~~~~~~~~~ 3. COMPLETEF~SCU~~;;~-UF'o.n (-d-~!J rvc.;::J..( I ~ v '2-"~' f./'''''' ~ hu[tiUrlZea SlgnatUCf' I LEGAL DESCRIPTION J~. OJ'b~ . b/'10c) JOB DESCRIPTION '~;_,;~'-W.\i'{\O ?OI.d'X f"hh ( Permit~ are )non-;ransfer,}.,le and expire ~ not started within 180 days of issuance or if work is Suspended for 180 days, 200 Amps or less 201 Amps to 400 Amps 401 AmEs to,IiOO Amps mures yOU lv ENTION:Oregon laW re'tj~Q~'Rll.'}fRiWOO Amps J%1Je 'I_~ ~nopted by the COver ~oggt\'lVpsNollS follow,~" Those ruIER1ar r2100 lotitication cent~~1O through o1>.mgj - , OAR 952.09.1- , ' - <June rlllles., . Supervisor License Number ' . _ ,.:, ;';''"v obtam cOplte Tern~'lfdReServlces or Feeders Ou"v. (-- 'Note' the tele!' II' g the center. \ '", MI~i'ication Expiration Date ca In. 'M thA Oregon Utlhi'nstll hon, Alteration or Relocation IIu..,\:'vf -. At'\!' "l"l??"l!\d , .# /,;,'/") t>'" "_."':0" - 200 Amps or less ./ $50.00 '17 "':v. Coostr, Cootr. Number 201 Amps to 400 Amps $ 69.00 _ _ NOTICE' 401 Amps to 600 Amps $100.00 Explral10n Date T''',:>' Q 600 A 1000 V 1 "B" b 11110 rct1IVIII ~HALL Fl<p/er. ..... mps 7' .._ .0. IS see a ove. Signature of Supervising Electrician AUTHORiZED UNDER r~,s~E~~itf~uGflK ... COf:i1v1ENCED OR is ABmW'aN~'l5a~~~~Plxteosion Per Panel f;" \ Hm DAY PERIOD, One Circuit ~ /A Each Additional Circuit or with _)/""".) ,k"""" Service or Feeder Permit Owners Name (/ vN l/.J'-fC.- Address ...l/ '" d C!?I t, 'r-. ".,/ r:. I' 7" Ci~W Phone /V/-J"cJ:?~ 2, CONTRACTOR INSTALLATION ONLY Electrical Contractor -r; I::e tlf"it.'-I7?J/1"~ Address City OVVNERINSTALLATION The installation is being made on property I own which ;'7';M '"", '~.M =, ~7~A~ J Inspection Request: 726-3769 A, New Residential- Single or Multi-Family per dwelling unit. Service Included 1000 sq, ft. or less Each additional 500 sq. ft, or portion thereof $106.00 $ 19.00 Each Manufact'd Home or Modular Dwelling Service or Feeder $50.00 B, Services or Feeders- Installation, Alterations or Relocation: ,/ $ 63.00 $ 75.00 $125,00 $163,00 $375,00 $ 50.00 $ 43.00 $ 3,00 E. Miscellaneous (Servi~~/feeder not included) -Each In~tall"tion Pump or irrigation Sign/Outline Lighting Limited EnergylResidential Limited Energy/Commercial $ 50,00 $ 50.00 $ 25.00 $ 45.00 Minimum Electric Permit Inspection Fee is $45.00 + Surcharges 4. 00.- :;J, "56 S, .-- 5~,<30 7% State Surcharge 10% Administrative Fee TOTAL Shared Drive(T:)IBuiJding Fonns/Electrical Pennit Application 1-03.doc .. C~nstr~ctio~ Contract. Board I). , , . . , , , . ". ,.' -. .' 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#: ~~~(} . Address: . ~.~ ~~~ c..\ Issued by: cP( Ii." f ~ Date: l- ;;';;;.-ot.../- Statement: Information Notice to Property Owners About Construction Responsibilities Note: Oregon Law, ORS 701,055(4) requires residential construction permit applicants who are not registered 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 registration 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: 1I1 1. 1 own, reside in, or will reside in the completed structure. D 2, I understand that I must register as a construction contractor if the structure is sold or offered for sale before or on completion. D 3A, My general contractor is (Name) (CCB #) I will instrucl my general contractor that all subcontractors who work on the structure must be registered with the Construction Contractors Board, OR m 3B, I will be my own general contractor. If! hire subcontractors, I will hire only subcontractors registered with the Construction Contractors Board, If! change my mind and hire a general contractor, I will contracl with a contractor who is registered with the CCB and will immediately notify the office issuing this building permit of the name of the contractor, certify that the above information is correct and that I have read and do understand the Information Pmp:~~.n rZ~::;" Rapo..;b;!;"'" <b. ~.n. .~/;: fu:, (Signature 0 permit apphcant) I ~ Y (White copy to issuing agency permit file, pink copy to applicant.) prop-own/f/3.99 '-- -', ,e, !~} . ..,""::\;("r""r"'::) ..., '\ TInft'ormatiO'~otice to Property Owners AlOoQJIt Construu:tnon lReslPonsnlOmtnes .. ~ . c:--.! ,;..f/ Z' ....,J #... ~ Note: This Information Notice 10 Property Owners ahout Construction Responsibilities was developed by the Construction COlltractors Board in aecordance with ORS 701.055(5). 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, JEm IPlloyer lReslPonsnlOmtnes If you hire persons not registered with the Construction Contractors Board to do labor in constructing or assisting in the construction or improvement of a residential structure. you will, in most instances. be ruled to be an employer and the people you hire will be employees, 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 more infonnation, call the Oregon Department of Revenue at 503-945-8091, 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, call the Oregon Employment Department at 503- 378-3524. 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 may be subject to penalties and will 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 503-947-7810. . 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 more information, call the Internal Revenue Service at 1-800-829-1040, Otlhier lReslPonsnlOn!ntnes and! Areas oft' Concems Code compliance: As the permit holder for this project, you are rcsponsible for resolving any failure to meet code requirements that may be brought to your attention through inspections. Liabilil)' 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 ovcrspray. water damage from pipe punctures, fire. or work that must be re-done, Time to supervise employees: Make sure you have sufticient time to supervise your employees. Expertise: Make sure you have the expertise 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 can perform the required inspections. If you have additional questions, write or call the Construction Contractors Board (PO Box 14140, Salem, OR 97309-5052. 503-378-4621). The Board is located at 700 Summer St NE, Suite 300. in Salem. prop-own/fl 3-99 . . ) ) 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number SHR2004-000 19 COM2004-00090 COM2004-00090 COM2004-00090 Payments: Type of Payment Check -.r~~~" " Wir...'...................".'.. .... I '. : i . ,. Receipt #: 1200400000000000090 Description LDAP Single Family Dwelling Temp Power 200 amps or less + 7% State Surcharge + 10% Administrative Fee . Paid By STEVEN HOUSER Received By tj Check Number Batch Number Authorization Number 9528 _. City, of Spdngfield Official Receipt Development Services Departmen4 Public Works Department Date: 01/22/2004 8:55:40Al\-J1 Amount Paid 300,00 50,00 3.50 5.00 S3511.5U Item Total: How Received In Person Payment Total: Amount Paid $358,50 S3511.5U . . " r_~; ~ J 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone Job/Journal Number SHR2004-000 19 COM2004-00090 COM2004-00090 COM2004-00090 ~.' Receipt #: 1200400000000000090 Description LDAP Single Family Dwelling Temp Power 200 amps or less + 7% State Surcharge + 10% Administrative Fee Payments: Type of Payment Check i.l1c~~ n uoliter Batch Number Authorization Number Paid By STEVEN HOUSER Received By tj 9528 ->;. City,of Spcingfield Official Receipl Development Services Departmen4 Public Works Departmenl ., Date: 01/22/2004 8:55:40AIW Amount Paid Item Total: 300,00 50,00 3,50 5.00 $358.50 How Received In Person Payment Total: Amount Paid $358.50 $358.50