HomeMy WebLinkAboutPermit Electrical 2011-6-13
Electrical Permit Application
CITY OF SPRINGFIELD, OREGON
225 Fifth StreeC+Springfield, OR 97477+PH(541)726-3753+FAX(541)726-3689
~~
DEPARTMENT USE ONLY
ClO
Date:
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.
CONTRACTOR INSTALLATION Branch circuits: new, alteration, extension per panel
Business name: (Jr{\ li A f ~ 11 /.n V\ (J AA a. Fee for branch circuits with purchase o1'a service or feeder fee:
Address: I '5l ~. L ~~ LJI r.iJ j :J- -..J Each branch circuit I $ 6.00 I $
City: c. Y)y \ .v'\/lD ~l J it State: nQ ZIP: ct1Li'--y.-r:.. b. Fee for branch circuits without purchase ofa service or feeder fee:
Phone:04/-7L1 -Il"'~ I Fax:'i'')Y/-7L/I-03U- First branch circuit (2) $ 55.00 $
E-mail: tt..o..{oJoml~dnnrJ..bWIYlV11.1.l 171",/\ Each additional branch circuit $ 6.00 $
CCB license no.: U::rr?.l',\ BCD license no.: U Miscellaneous fees: service or feeder not included
Signing supervisor's license no.: L\.L\. ()S LEA Each pump or irrigation circle (2)
Print name of signing supervisor:.'7--r ~ 0\'\ i.v\ 0,.. ~ ^. J!y. ",. };:~ch sign or outline lighting (2)
. f" '. .I\,b...CJ:.. <1IA ~- 11- Signal circuit or a limited-energy panel,
Signature 0 slgnmg supervlsor.~ "I ~ alteration, or extension (2)
I Each additional inspection: (1)
"<~"s;';o
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LOCAL GOVERNMENT APPROVAL
Zoning approval verified? DYes D No
CATEGORY OF CONSTRUCTION
o Residential I 0 Government la-Commercial
JOB SITE INFORMATION AND LOl;:ATION
Job site address: n~ ) ~. 71-;:::). Y"\.q
City: 0.",,- )(\ ,A ^ r', (, \ rI I State: llR- ZIP: ctlL\ r b
Reference~ \ 11)'1 .?1\ nO I Taxlot.:( J{ J: "] Jl. -
~. ... DESCRIPTION OFWORK" ,
Qsz ~ \lJra. ~ i= I Y ~ A-\. (jJ .rYV\.
Q... J^ Q J
PROPERTY OWNER .....
Name: tt ') \ \ \ r) f'fVl b 11, t1..9-- m ~ y tY~
Address: ~,t:=..) I-) <~I f\r~i
City:...I)t\-n I fll'\.t.t ',lIf!t!!te: JL ZIP: C-f14"1::
Phone: ~ ~ - \ \
E-mail:
Fax:
This installation is being made on residential or fann 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).
Signature:
440-2584-) (9/08/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
Limited 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) $ 8t.00 $
201 to 400 amps (2) $ 95.00 $
401 to 600 amps (2) $158.00 $
601 to 1,000 amps (2) $205.00 $
Over 1.000 amps or volts (2) $469.00 $
Reconnect only (2) $ 63.00 $
Temporary services or feeders: installation, alteration, relocation
200 amps or less (2)
201 to 400 amps (2)
401 to 600 amps (2)
$ 63.00 $
$ 87.00 $
$126.00 $
Over 600 amps or 1,000 volts, see services or feeders section above
$ 63.00 $
$ 63.00 $
i $ 63.00 $li31-
$58.00 $
APPLICANT USE
(A) Enter subtotal of above fees
(Minimum Permit Fee $58.00)
$lt3,.f-
$i.'S,l(
$--:0.\<
n'b:-' 1\
(B) Enter 12% surcharge (.12 x [A])
(C) Technology Fee (5% of [A])
TOTAL fees and surcharges (A through C):
sp. R~~L~
~
~EGON
TRANSACTION RECEIPT
CITY OF SPRINGFIELD
225 Fifth St
Springfield,OR 97477
541-726-3753
WNW.ci ,springfield.or. us
811.SPR2011-01390
250 S 32ND ST
permitcenter@cLspringfield.or.us
RECEIPT NO: 2011001572
lOESGRIP..TIONi
Fire Alarm
State of Oregon Surcharge (12% of applicable fees)
Technology fee (5% of permit total)
RECORD NO: 811-SPR2011.01390 DATE: 0611312011
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224.00000-426102 63.00
821.Q0000.215004 7.56
100.Q0000-425605 3.15
TOTAL DUE: 73.71
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,,' CASHIER:;L!HOPPER~~;:"::\ '.;i,)!!tC0MMENTSin:j:L:iii,,~;:}<,:+<<r:li:i'4Wll;(TI:" .'.: \., . .' "" 11_ ',~~~illlly"Ah "
OMUD & SWINNEY FIRE 73.71
PROTECTION & SECURITY INC
I
PAYMENT rYP'E"
Check
TOTAL PAID:
73.71