HomeMy WebLinkAboutPermit Electrical 2006-12-12
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INITIALS NM
DATE Idll?/O<47.
SOURCE rYYllps p2-J~~
\ 7.,/11-/ 'LdJ6
225 FIFTH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-3689 .
ELECTRICAL PERMIT APPLICATION
City Job Number COIA/1 2006-0 159/ Date
Over 600 Amps or 1000 Volts see "B" above.
D. ' Branch Circuits
N ~.c ..",L.. ..,,"
dJ CNBf'Alteration or Extension Per Panel
THIS~~p;.it \ $ 43.00 Cf :J
AUTHficy~''t!ddit$MALq:~,..or with b
'-:> / I COMM~eUlJe@rlJNrJrFfMMIRE IF Tit 1, $ 3.00
'(--=d//Ao1h~ ENCED 0 " THIS PERRA," t l1'ORK
.5.f- A NY F1J 9 M,lf~W'~6Ss4~Nr1B",~~(f~r' 'ldlS'Nt'Jted) -Each Installation
ERlOD /YED FOR
Phone 7Cfb ~51 (;, Z Pump or irrigation' $ 50.00
Sign/Outline Lighting $ 50.00
Limited Energy/Residential $ 25.00
Limited Energy/Commercial $ 45.00
Minimum Electric Permit Inspection Fee is $45.00 + Surcharges
4. ~SUBTOTAL?l!~~?VE'" l.{ 7
8% State Surcharge "> ~,
10% Administrative Fee 4 c;:e..>
5% Technology Fee 2.4)'
1. LOCATION OF INSTALLATION:
\ q l.{ S H. <.;t
LEGAL DESCRIPTION:
/7 ()S 3' 61 z...
044<J a
JOB DESCRIPTION:
AdJ..~~ c;rclAi-\-s tor \-\vAc >yskt11
Permits are non-transferable and expire if work is
not started within 180 days of issuance or if work is
Suspended for 180 days.
2.
CONTRACTOR INSTALLATION ONLY'
Electrical Contractor
Address
City Phone
Sop,,,;,o, U"o" Numbe, .J ~ Y
Expiration Date 0 /
Con"'. Cootr. Nom"'" /
Expiration Date
/
Signature of Supervising Electrician
Owners Name" r c::vV<\....
If
Address
194~-
S?;:~
City
OWNER INST ALLA nON
The installation is being made on property I own which
is not intended for sale, lease or rent.
Owners ~ature.:. ......-; "
~ - ~\ (-JjvJ
Inspection Request: 726-3769
3. CO.MPLETE FEE SCHEDULE BELOW
A. i New Residential- Single or Multi-Family per dwelling unit.
Service Included
1000 sq. ft. or less
Each additional 500 sq. ft. or
portion thereof
Each Manufact'd Home or
Modular Dwelling Service or
Feeder
$106.00
$ 19.00
$50.00
B. Services or Feeders -Installation, Alterations or Relocation:
/ 200 Amps or less $ 63.00
201 Amps to 400 Amps $ 75.00
401 Amps to 600 Amps $125.00
6.dt~~.Jtt:>It9P'p' Amps $163.00
NlR.YPi41<6CD1_~W8bl90'lldW fF~qU/(: $375.00
,~ygffim~fi~m ad by the Or. 6~ Yf$I$(/jC9l0
~~~~l e'~~=~U:~t
calfOn@ ~hlS un COPDtaiS if! ~A 952-001
'l41/iib!hl~r~~i~i~o~~IWjg~oW"D~ rUles ~
200 A~iWEJF~sOr~fJon Utility AJ.~/~?hOYie5'(J.oo
201 Amps to 400 lriYJo-332_234~'4'l'icati$1i9.00
401 Amps to 600 Amps . $100.00
TOTAL
to 7J-
Shared Dnve(T:)/Building Forms/Electrical Pennit Application 8-06.doc
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
SITE ADDRESS: 1945 H ST
ASSESSOR'S PARCEL NO.: 1703361204400
CITY OF SPRINGFIELD'
Building/Combination Permit
PERMIT NO: COM2006-01591
ISSUED: 12/12/2006
APPLIED: 12/12/2006
EXPIRES: 06/12/2007
VALUE:
Springfield TYPE OF WORK: Heating System
TYPE OF USE: New
Residential
PROJECT DESCRIPTION: Install hvac system
I BUILDING INFORMfF~'
~ ~;;.O ~.
# of Stories: ~ ~ ~~ ~~. ~ Lot Size:
R-3 Height of Stru~u~ ~& ~Q ~\SI ~ Sq Ft 1st Floor:
Type ofHe~ ~~. ~ r:e ~a c;il~'O Sq Ft 2nd Floor:
VB Water Type: ~6e::! ~~ c:;. ~ CV &~ ~ ~q Ft Basement:
Range Type: ()~'O ~& ~ 7~ &~ ~~~t Garage/Carport
A'.. Energy Path: <i>.., ~~ 0&.., ~~ V-o ~ ~~J. Other:
/: "'0\ Sprinkled Buildir?~.&Q~ ~ ~ Od'C9<!tu1i3,.t Load:
.. 0.-, ".# /^ A' _ ^ ~ ;4 " S'l,
'0 '~~J>~~itOPMENT INFORM~~\ ~&. ~ V~\SI e~.~U'
~~,~ '-4. ~:\ ~:~\S'o ~~'& ~~QJJIREDPARKING
?~ 8 '''l'A 't? ~. & ~ ~ \2 ~~ ~,
~ ~ ~ YlverlayDist: ~~~~'&~~C9 ~)~~:c
o ~ ~~eetTreesRqd: ~o~.~~~~~~capped:
~..t-..o ~ _'~~ Drive Rqd: ~ ~ o~ &\SI ~ofupact:
~ -(f>Ol<<60;~.l>coverage: ~~o & ~$
~~~r~ "
IPUBLIC~~~~ENTSI
~ ~ ~ Sidewalk Type:
Y'~ ~ 70
~ ~ ~ Downspouts/Drains:
/'
Owner: TREVOR ROLLMAN
Address: 1945 H ST
SPRINGFIELD OR 97477
Contractor Type
Electrical
Mechanical
Contractor
OWNER
OWNER
# of Units:
Primary Occupancy Group:
Secondary Occupancy Group:
Primary Construction Type
Secondary Construction Type:
# of Bedrooms:
Frontyard Setback:
Side 1 Setback:
Side 2 Setback:
Rearyard Setback:
Solar Setbacks:
Street Improvements:
Storm Sewer Available:
Special Instruction:
Notes:
Phone Number: 541-746-5168
I CONTRACTOR INFORMATION I
License
Expiration Date Phone
Pal!:e 1 of 3
Status
Issued
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
Description
Tvpe of Construction
Fee Description
-Mechanical Issuance Fee-
+ 10% Administrative Fee
+ 5% Technology Fee
+ 8% State Surcharge
Add, Alter, Extend Circ
Add, Alter, Extend Circ Ea Add
Appliance Vent
Boiler/Comp Up To 100,000 btu
Furnace - up to 100,000 btu
Gas Outlets 1-4
Minimum/Adjustment Mechanical
Total Amount Paid
CITY OF SPRINGFIELD -
Building/Combination Permit
PERMIT NO: COM2006-01591
ISSUED: 12/12/2006
APPLIED: 12/12/2006
EXPIRES: 06/12/2007
VALUE:
I Valuation Description I
$ Per Sq Ft
or multiplier
Square Footage
or Bid Amount
Value
Date Calculated
Total Value of Project
~
Amount Paid
Date Paid
Receipt Number
$10.00
$9.40
$4.70
$7.52
$43.00
$6.00
$6.00
$12.00
$12.00
$4.00
$11.00
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
12/12/06
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
2200600000000001687
$125.62
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.
~eouire<U'nsnections .
Gas Service: After line is installed and line has been connected to a minimum of one appliance including required
testing. Presure test done at this point.
Rough Mechanical: Prior to Cover
Final Mechanical: When all mechanical work is complete.
Rough Electric: Prior to Cover
Final Electric: When all electrical work is complete.
Pa2e 2 of 3
Status
Issued
CITY OF SPRINGFIELD
Building/Combination Permit
PERMIT NO: COM2006-01591
ISSUED: 12/12/2006
APPLIED: 12/12/2006
EXPIRES: 06/12/2007
VALUE:
225 Fifth Street, Springfield, OR
541-726-3753 Phone
541-726-3676 Fax
541-726-3769 Inspection Line
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.
~ ,~
"~~J~
11., 117-/06
. .
Owner or Contractors Signature
Date
Pa2e 3 of3
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 #: UJM 20'0 ..::>. - 0/ ')9 /
.S+-
/9L( S- Jf
-:J::>~
Date:
/Z/;z.-/OG
I
Address:
Issued by:
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
perinit 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.
D 3A. My general contractor is
(Name)
(CCB #)
I will ins1:rl;lct my general contractor that all subcontractors who work on the structure must be
licensed with the Construction Contractors Board.
OR
-(" 3B. I ~i11 be my own general contractor.
,
If I hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors
Board. If! change my mind and hire a general contractor, lwill contract with a contractor who is
licensed with the CCB and will immediately notify the office issuing this building permit ofthe
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.
~~(2A- --. t'l-/tt/t>(,
(Signature of permit applicant) (Date)
(White copy to issuing agency permit file, pink copy to applicant.)
Property- owner. doc 06-01-04
A~!nID1g ~~ "')t @~rt._OWinr GelllleJr.~1 ~~)nTI~t:rj!ctor;?
" . '. J ,. t ' , '. .. ~ . ,_ ."
- INFORMATioN NOTICE TO.PROPERTY oWNERS ' .' ."
ABO~T. CONSTRlUCTION, RESPONSIBIliTIES
_~_ .~ ~ 'I
, "~ .. i .
'.
.~ \
..
,
NOTE: This Information Notice to Property Owners about Construction Responsibiiities was developed by the
Construction Contractors Board in accordance with ORS 701.055(5), passed by the 1989 Oregon Legis/ature.
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 be~ng aware of the folloWing responsibiliJies and concerns.
Employer Respoll1lsibilities
. " . . '. .'.. " ..
You will; in most,in~tances, be ruleq to be an '~employer" a,nd the contractors you contract with.will1;>e"employees" if
, you use contract~rs not licensed witl~ -the Construction Contractors Board to do labor in c~mstructingor toa~~ist in the
construction or improvement of. a resi4ential structure. As the .e)Mp'loyell", you must comp~y with the foRlowi~g:
- .' . ~ ,\..... . - .
Oll"egolll'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 information, calf the Department of'Reverllie at 503.:378-4988. . ' . .
UnnempBoymelllt XnsuJrall1lce Tax: As an employer, you are required to pay a tax for unemployment insurance purposJ~..-
on the wages of all employees. For more information, call the Oregon Employment Department at 503-947-1488.
.~'.',:i _ .. '.....
The Oregon Business Identification Number (BIN) is a combined number for ~ot~ Orego~ Wi~olding and
Unemployment Insurance Tax. To file for a BIN, can 503-945-8091 or www.dor.state.or.us/formsnav.htmll. for the
appropriate forms. . .
Workers' Compensation Insurance: As an employer; you are subject to the Oregon Workers' Compensation Law,
and must obtain worke~s' compensation insurance.for yo~ 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 emplQyees 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 JRevcnme 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 EIN number, call the
IRS at 1-800-829-4933 or-visit their web site atw"\l.o-Woirs.lIov.
Other llesponsibilities all1ld Area~ of Co~~er]ills
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 attenti~n through inspe,ctions,
"
Liability and Property Damage IlIlsuJralIlce: Contact yo~r insurance agent to' s~e if you have ad~quate insunmce
coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe punctures, fire or
-{\.\ .
work that must be red<:!l~.' , "'...
.':". .
":,
Time: Make sure you have sufficient time to supervise your employees.
. ~ ". .. 1 . , "
Expertise: Make sure you have the skills to act as your own generaic'ontiactor, 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 call the Construction Contractors Board (503-378-4621) or write the agency at PO
Box 14140, Salem, OR 97309-5052.
Property _ owner.doc 06-01-04
225 Fifth Street
Springfield, Oregon 97477
541-726-3759 Phone
C;~' of Springfield Official Receipt
1 .:lopment Services Department
Public Works Department
Job/Journal Number
COM2006-01591
COM2006-01591
COM2006-01591
COM2006-0 1591
COM2006-0 1591
COM2006-01591
COM2006-01591
COM2006-01591
COM2006-0 1591
COM2006-0 1591
COM2006-01591
Payments:
Type of Payment
CreditCard
cReceintl
RECEIPT #:
Date: 12/12/2006
2200600000000001687
Description
Furnace - up to 100,000 btu
Boiler/Camp Up To 100,000 btu
Appliance Vent
Gas Outlets 1-4
Minimum/Adjustment Mechanical
-Mechanical Issuance Fee-
Add, Alter, Extend Circ
Add, Alter, Extend Circ Ea Add
+ 5% Technology Fee
+ 8% State Surcharge
+ 10% Administrative Fee
Paid By
TREVOR ROLLMAN
Item Total:
Check Number Authorization
Received By Batch Number Number How Received
djb 223047 In Person
Payment Total:
Page 1 of 1
1:43:42PM
Amount Due
12.00
.12.00
6.00
4.00
11.00
10.00
43.00
6.00
4.70
7.52
9.40
$125.62
Amount Paid
$125.62
$125.62
12/12/2006