HomeMy WebLinkAboutPermit Electrical 2011-4-25
Electrical Permit Application
F -
225 Fifth Street+Springfield, OR 97477+PII(S41)726-375J+ FAX(54I)726-3689
Date: q --- :J'::;-.- 2.(z> (
This permit is i,ssued under OAR 918-309-0000. Permits are nontransferable. Permits- expire if work is Dot started within 180
days ofissuance or if work is suspended for 180 days. .
LOCAL GOVERNMENT APPROVAL
Zoning approval verified? 0 Yes 0 No
CA TEGORY OF CONSTRUCTION
Residential 0 Government 0 Commercial
JOB SITE INFORMATION AND LOCATION
Job site address: .:2/tRS' /l7 If;/? LooP
City: .5 ;e. t: /) State: O,€ ZIP: 1'/77
Reference: Taxlot.:
DESCRIPTION OF WORK
Rc 's eel 1M dl/e'Ri - /'", /l1ifl/M. LJ4l3eL
ADT JOB :._ 81f- 'I~2?! r:LS~1/ISO
PROPERTY OWNER
Name: /JAJ ff C; /feci,'NE If!.-
Address: :5ftme
City:
Phone:57'i -7';-
E-mail:
This installation is being made on residential or furm property
owned by me or a member of my immediate family. This
property is not intended for sale, exchange, lease, or rent. OAR
479.540(1) and 479.560(1).
ZIP:
Signature:
CONTRACTOR INSTALLATION
Business name:
ADT Security
Address:
2815 SW 153rd Dr
City': ZIP: 9 7 0 0 6
Phone: Fax: 503-469-7Il4
E-mail: spate@adt.com
CCB license no.: 59944 CD license no.: 26 _ 209 C L E
Signing supervisor's license no_: 389 LEA
Print name of signing supervisor:
Signature of signing supervisor'
/
,/
':
440.2584.) (9108/COM)
FEE SCHEDULE
Number of inspections per item ( ) Qty, Cost Total
ea. cost
Residential, per unit, service included:
1,000 sq. ft. or less (4) $134.00 $
Each additional 500 sq. ft. or portion $ 25.00 $
thereof
LilT!itcd.energy (2) $ 32.00 $
Each manufactured home or modular $ 63.00 $
dwelling service or feeder (2)
Services or feeders: installation, alteration, relocation
200 amps or less (2) $ 81.00 $
20 I to 400 amps (2) $ 95.00 $
40 I to 600 amps (2) $158.00 $
60 I to 1,000 amps (2) $205.00 $
Over 1,000 amps or volts (2) $469.00 $
RecOImect only (2) $ 63.00 $
Temporary services or feeders: installation, alteration, relocation
200 amps or less (2) $ 63.00 $
20 I to 400 amps (2) $ 87.00 $ .
40 I to 600 amps (2) $126.00 $
Over 600 amps or 1,000 volts, see services or fceders section above,'
Branch circuits: new, a/feraJion, extension per panel
a Fee for branch circuits with purchase of a service or Feeder fee:
Each branch circuit $ 6.00 I $
b. Fee for branch circUits without purchase of a service or feeder fee;
First branch circuit (2) $ 55.00 $
Each additional branch circuit. $ 6.00 $
Miscellaneous fees: service Or feeder not included
Each pwnp or irrigatio~ circle (2) $ 63.00 $
Each sign or outline lighting (2) $ 63.00 $
Signal circuit or a limited-energy panel, .>
,::...... $ 63.00 $
alteration, or extension (2) .-
Each addjtional inspection: (I) I $58.00 $ ;.:y
APPLICANT USE
(A) Enter su~t~ fees ') cP
FSg' 1
(Minimum Pe It Fee $58.00) , , .. ~--,'
,
(B) Enter 1,2"/0 Atrcharge (.I~ $ f~i;-;t1/f
q'
(C) Technology Fee (5% of[An $ ~~9-'2
TOTAL fees and surcharges (A through C): ~fik
$ _,-1.,.
,\
.
SP~~N:. :EL~
L~~
~ORfGON
www.ci.springfield.or.us
TRANSACTION RECEIPT
811-SPR2011-00612
2765 MAlA LOOP
CITY OF SPRINGFIELD
225 Fifth St
Springfield,OR 97477
541-726-3753
permi1center@ci.sprlngfield.or.us
'.' 'i'ArJiO:liNT_DUE'-'.~,~~'i
26.00
32.00
6.96
2.90
-...-....-.--.....--
TOTAL DUE: 67.86
Cp-...ylVl~~fjxFiE:1:8Aj:()~~;CASHIER:NMACHADO;;~:[::fr:"c.QMME~fS;~~~;,;;<l;[.;;; _ ,..,.. .;JAMc>I.[NN?i\ID ;. ;';. . '.. :..J
Check ADT SECURITY SYSTEM, INC. 67.86
0123851
RECEIPT NO: 2011000792 RECORD NO: 811-SPR2011-00612
[OESCRIP..TION:i;. . i.... . 'rc.I",'?..;;;,;,., .;.~;;,-" ;-'.;,,;.,.::..::',:'ACcOUNLCObEHtF'" "
Balance of Minimum Electrical Permit Fees 224~OOOOO~426102
Limited energy, residential (with above sq It) 224-00000-426102 ~___._.._
State of Oregon Surcharge (12% 01 applicable fees) 821.00000-215004
Technology fee (5% of permit total) 100-00000-425605
DATE: 04/25/2011
TOTAL PAID:
67.86