HomeMy WebLinkAboutPermit Electrical 4-23-98
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225 FIFTH STREET Authorized Signature \'\ M ELECTRIC{U. PERMIT APPLICATION
SPRINGFIELD, OREGON 97477' " \ a f
INSPECTION REQUEST: 726-3769 City Job Number -/ f3 0 1 ~
OFFICE: 726-3759
1.
LOCATION OF INSTALLATION
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LEGAL DESCRIPTION
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, JOB DESCRIPTION
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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
Supervisor License Number
Expiration Date
3 . COMPLETE FEE SCHEDULE BELOY
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
Each Manuf'd Home or
Modular Dwelling
Service or Feeder
B., Services or Feeders
'Installation, Alterations
or Relocation:
20Q amps 'or less
201 amps to 400 amps
401 amps to 600 amps
601 amps to 1000 amps
Over 1000 amps/volts
Reconnect Only
Items Cost
Sum
$ 85.00
$ 15.00
,$ 40.00
$ 50.00
$ 60.00
$100.00
$130.00
$300.00
$ 40.00
C. Temporary Services or Feed~rs
Installation, Alteration or Relocation
Constr Contr. Number
Expiration Date
Signature of Supervising Electrician
Owners Name_~-I/MY7 f ~ac.....-k
AddressJ4tJ A/La. ) ~e
City ~~ Phone ?#;-{?9?
O\1NER INSTALLATION
The installation is being made on
property I own whi~h is not intended
for sale, lease or rent.
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DATE: .fl 2 3//,g
RECEIPT #: (-j,., ~ e:r /? '
RECEIVED BY: ,//~
/IT /~
D.
200 amps"oT less II
201 amps to 400 amps
Over 401 to 600 amps
Over 600 amps or 1000 volts
Branch Circuits
$ 40.00
$ 55.00
$ 80.00
see "B" above
New, Alteration or Extension Per Panel
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One Circuit I/'" $ 35.00 J:)'''O
Each Additional
Circuit or with Service
or Feeder Permi t 2- $,2.00' 4. cro
not included)
Miscellaneous (Service/feeder
-Each installation
Pump or irrigation
Sign/Outline Lighting
Limited Energy/Res
Limited Energy/Comm
E.
5.
SUBTOTAL OF ABOVE
5% State Surcharge
3% Administrative Fee
TOTAL
$ 40.00
$ 40.00
$ 20.00
$ 36.00
39,00
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Permit#: CJ~(,~.e:f( ~
Address: left) A?"~ Av~
Issued by: ' / ~ _ Date: 4/;"} j, f6
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Statement: Information Notice to Property Owners
About Construction Responsibilities
Note: Oregon Law, ORS 701. 055(4), requires residential construction permit appli-
cants who are not registered with the Construction Contractors Board to sign the
following statement before a buildingpermit can be issued. This statementis 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 I and 2, and either box 3A or 3B:
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I own, reside in, or will reside in the completed structure.
2. I understand that I must register as a construction contractor if the structure is sold or offered for sale
before or upon completion.
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3A. My general contractor is
(Name) Contractor regis. #
I will instruct my general contractor that all subcontractors who work on the structure must be
registered with the Construction Contractors Board.
OR
KJ 3B. I will be my own general contractor. '
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IfI hire subcontractors, I will hire only subcontractors registered with the Construction Contractors
Board. If I change my mind and hire a general contractor, I will contract 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.
I hereby certify that the above information is correct and that I have read and do understand the Information
Notice to p~= od;!t~struction Responsibilities on the reverse side :;: f:~6
(Signature of-permit applicant) (Date) /
(White copy to issuing agency permit file,
pink copy to applicant)
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UWoli'm'~~eo'u:il :Notice to Property OWrrilers
AbQl\.lIt_9orrilstrtU.~toorril ResjpJohsilbmtoes
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Note: This Information Notic.e-tq Property Owners ahout Construction Re"ponsibilities
':\11;(15 developed by the-Constrl/ction COlitractors B~cird in accordance with ORS 701.055(5),
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If you are acting as your own contractor to construct a new home or make a sul1stantial improvement to an existing structure,
you can preventmany problems by being aware oftheJolJowing.responsibilities and areas of con, cern.,
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EMPLOYER RESPONSIBlqrIES:
If you hire persons not I:egistered with the Constru,cti99.Contrac.~ors Board to, dq l~bor in constructing or assisting in the
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construction or improvement ofa residential structure, you \vill, in~most instances, b~ ruled to be an employer and the people
, \ ",', .'.."... _ ' .':" ".' .'_ .' '.' r '. .
YOll hire will be employees. As the employer, you mustt;:;oinply \vith tne foIlO\virig: -,"
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Oregon' s withholding tax la\\': As ail employei-,.you must withhold incom~ taxesfroin em'pl~yee wages at ihetime employees
are paid. You wi II be 'liable 'tor'the ta'x'paymentS evenif~ybtl doh'! actUally-witllhold the 'ta~' from' yohr,employees. For more
information, call the Oregon Dept. ofRevenueat945'"809L:' -..'-.", .' ,.,., ,', -",
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 inform,ation"calHhe, Or~golJ EmplgymentDepartmer;rt aq78~3524: .
WOI:kers' compensation i~sil~ance: AS,an employer, !:?u ar~ e~I?Je~!}?Jr~p~egon\~ ,?r~ers' COn;\p~nsa.tion_ Law, and'm,~~L
obtam workers' compensatIOn 1l1surance tor your employees. I fyou faIl to obtam workers' compensatIOn 1l1surance, you n)a):...: '
be subjectto penalties and wi 11 be I iable tor all claim costs if one of your employees is injured on the job~ For more information,
can-tl)~\Vot'Kers"Cornpensat16n Divi~ion atth~ Departrtient ofCSr1immer ~nd!B'~sines's Sb-vice; at'945:.7888. ", ;) "
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u.s. nnternal Revenue Service: As an employer, you must withhold federal income tax from employees' wages. You will, ~e
liable tor the tax paymente.ven if you didn't actually withhold the tax. Formore informati0n, call the Internal Revenue Serv:ice '
at 1-800..;829-1040.. ,., ;'~ I .
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OTHER RESPONSIBILITIES AND AREAS OF :CONCERN,:
, Codecompliance: As the perm it holderforthis project, you are responsible for resolving any failuretcimeet.code requirements
that may be brought to your attention through inspections.
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Liability and property damage insurance: Contact your insurance agent to see if you have adequate insurance coveragetc;r:'
accidents and omiss'ions,such as falling tools, paint ov~r~pray"water_damage.from pipe Pur1CtUf.~~, fire, or work that must be
re-done." ',' .. ",' " '..' .. ' . ',' -" /
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Time to s~~en.-i~~empl~~~es: M~k~ ~ure 'you :h~~e'suft~cient tim~ to slipervise your ernploy,ees.
Expertise: Make s~lre you have the e,xpertis,e to act as your own general contractor, to coordinate th9 work of rough-in and finish
trades, and'fo'notify build!.ng officials at t~e aplkopriatetimes so'they can perf6nrdhe required inspections: " ' '
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If you have additional,questions,write or call the Construction Contractors Board erO Box 14140, Salem, OR 97309-5052,
50~/378-4(>21). .The Bo~rd is located at 700 Summer St. NE Suite ~OO"in_?alem. -~. " ~
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