HomeMy WebLinkAboutPermit Electrical 2011-2-14
Electrical Permit Al!.plication
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225 Fifth Street. Springfield, OR 97477. PH(541 )726~3753. FAX(54 t )726-3689
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DEPARTMENT USE ONLY
I r~ Permit no.: 511 - ;2-~~1
Date: 2. 1"1 II
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.
LOCAL GOVERNMENT APPROVAL FEE SCHEDULE
Zoning approval verified? DYes DNo Number of inspections ,per item () Qty. Cost Total
ea. cost
CATEGORY OF CONSTRUCTION Residential, per unit, service included:
o Residential I 0 Governmcnt I !;d'tommercial
1,000 sq. ft. or less (4) $134.00 $
JOB SITE INFORMATION AND LOCATION
Job site address: 5?S5 MV'\Il\.:l Each additional 500 sq. ft. or portion $ 25.00 $
thereof
City: ('~~I) I Statc: l"nl. I ZIP: ~ '1'1'7K' Limited energy (2) $ 32.00 $
Reference: \' 1 J I Taxlot.: I' IN J\ Each manufactured home or modular
$ 63.00 $
DESCRIPTION OF WORK dwelling service or feeder (2)
I l 0 IilL "'r. I Services or feeders: installation, alteration, relocation
200 amps or less (2) \ $ 81.00 $f"f
PROPERTY OWNER 201 to 400 amps (2) $ 95.00 $
Name:~4-Y'~ J..........~TC6"'~ 401 to 600 amps (2) $158.00 $
Address: L'SZ;) 0..... i:aLfb 601 to 1,000 amps (2) $205.00 $
City: .U ~ I State: m I ZIP: n"ibc. Over \,000 amps or volts (2) $469.00 $
Phone: ~t -~~S- Gz1z,1:I I Fax: - . Reconnect only (2) $ 63.00 $
E-mail: U, ~ L> .b~ r\ """ \..... ~ Temporary services or feeders: installation, alteration, relocation
This installation is being made on residential or farm property 200 amps or less (2) $ 63.00 $
owned by me or a member of my immediate family. This 201 to 400 amps (2) $ 87.00 $
property is not intended for sale, exchange, lease, or rent. OAR 401 to 600 amps (2)
479.540(1) and 479.560(1). $126.00 $
Signature: Over 600 amps or 1,000 volts, see services or feeders section above
CONTRACTOR INSTALI.A.TION Branch circuits: new, alteration, extension per panel
Busincss name: /: - ~ a ecl-N "-- ...L;;; (' , a Fee for branch circuits with purchase of a service or feeder tee:
Address: <;;Po l:)O)( .... ~(., Each branch circuit 2- 'J $ 6.00 ~
City: 'Zt9C1f'I"\P , I State: (!) fL I ZIP: 97'10 I b. Fee for branch circuits without purchase of a service or feeder fee:
Phone: s<iJ -)<" ~ ,)Ya9 I Fax:c;<l-l - 'I f? tr-f ~ocl First branch circuit (2) $ 55.00 $
E-mail: /L 1 ..,~ .Je\.'€'c...~c... CO~ Each additional branch circuit $ 6.00 $
CCB li~no.:Jt:3j.j9/ I BCD license no.c:;o..::lea 7{" Miscellaneous fees: service or feeder not included
Signing supervisor's license no.: *7 tf-5 ....... Each pump or irrigation circle (2) $ 63.00 $
Print name of signing supervisor: rr.'=,. I kL ~ ... a:>w.)/I'l.'S Each sign or outline lighting (2) $ 63.00 $
Signature of signing supervisor: W.LL/ / Signal circuit or a limited~energy panel, $ 63.00 $
alteration, or extension (2)
/ '\ Each additional inspection: (I) $58.00 $
APPLICANT USE
~\ (A) Enter subtotal of above fees $..21 ~. ac:
(Minimum Permit Fee $58.00)
(B) Enter 12% surcharge (.12 x [AD $:u..~f
~,,\ (C) Technology Fce (5% of [AD $ lo9~
~ TOTAL fees and surcharges (A through C): $ 2S"~ .2 ~
440.2584-) (9/08/COM)
TRANSACTION RECEIPT
CITY OF SPRINGFIELD
225 Fifth St
Springfield,OR 97477
541-726-3753
www.ci.springfield.or.us
811-SPR2011-00234
5755 MAIN ST
permitcenter@ci.sprinQfield.or.us
RECEIPT NO: 2011000282
RECORD NO: 811-SPR2011-00234
DATE: 02/1412011
224-00000-426102 138.00
224-00000-426102 81.00
821-00000-215004 26.28
100-00000-425605 10.95
TOTAL DUE: 256.23
~'lMENTt;r;yPE;!!iifi!>i'eA'ioRl0!!!'e.l.SH1E1€Ci:AIi~~~iiJiii.1i'!!;"j50MMENTS.!!m!!!,!!'!'!:l!!';,'f,"!1f,,"1\i#i!~MQl.iij.t'I1Al[ji~!,'!;!~!!~!:ij
Credit Card GMD ELECTRIC INC 256.23
080505
Branch circuits with service or feeder each circuit
Services 200 amps or less
State of Oregon Surcharge (12% of applicable fees)
Technology fee (5% of permit total)
TOTAL PAID:
256.23