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Home My WebLink AboutPermit Electrical 2005-11-14 ,J 'I.".C . II" "'I'~I. I ,I. II' i.' .. Ij~~ll' I .'~~II ~p~ o\~o~~~~.,. i '~\~ "- ,\ h~\ f eC~:l-' ,r' --"1'~ 225 FIFfH STREET. SPRINGFIELD, OR 97477 . PH:(541)726-3753 . FAX: (541)726-36~~"..~\li\0-'S~':;;~ " ELECTRICAL PERMIT APPLICATION ",,,~~~~."0\\0L~~ ',~ \0\\0 6" City Job Number CoiM. ZOO" - D/l.(77 Date -I-'J!'ff0=~"f- or z.... o'4lJ. \f\\j- "I 3, ~c.O~.pk:i,n'FiiE~~iiE~~'-"C: '~",;~:-r, j _.._-4:.:;.......__"-_...----'""__-'---.. --~u'(Q- .---.-- _._~_."""":'-_._-' ~ ~".. 0-.\0 0 S'", (-) ?.o.-:"'~'i_;'i'"":':":"~"f,.-~m-;;'''''''-'''~''';-\.:...o'(~ke",-,.-~~. -'r .:'-~'. ~-' ~d.'~l- -:"i-; -, .,.--'.- '-,"-'~ ,-,"~-, A. li~!.i R~ideritial.,.,Sinj,4:~~~ti:I~i1y 'pe{~w~I~'Ji~~~J . ,'_ ~::-"-::r --'.' .'- ',,- :-'~-.., 1. ~i LOCATUJ.N OFINSr:4LAJ,!ON", 57"3.-~- ~-~ ~ f (T - c.A- LEGAL DESCRIPTION I ~6 'Lot.( l ( 07(00 JOB DESCRIPTION 5\~ L... ~ (y , Permits are non-transferable and expire if work is r not started within 180 days of issuance or if work is Suspended for 180 days. 2. fCONTRACTOR'rNS!4L0;rt'()N divLy, I 26'S I d t;.-c. e:!"" Electrical Contractor Address ^ TT~..__ _ / . " ,~.,' .u'". uregon~a ' follow rules ado')l~ci . equrres you 10 City Not't;r::ltir..... r-_ .' ~ho e lhG Or(,f')n 1:/ I hI , 0 --7"~" lC1:;o r I - In /,11 r;~~~ rn1 ~"'" - ~ -',' . OO:;J, Yud In , . J- supervisOr"CiC7nse Wnber -0 uy . nl,', ,is Expiration Dat dl:alion i ,). Constr, C tr. Number. Expira on Dale Signature of Supervising Electrician 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 lOb S7 I :> $ 19.00 $50,00 - -------.---- ....-..,..........._--. B. I"S,~ivic~or Feeders -,Irrstall~ti;lJ,., A~\eration,s or, Re),!~ation: i 200 Amps or less 20 I Amps \0 400 Amps 401 Amps to 600 Amps 60 I Amps to 1000 Amps Over 1000 AmpsIVolts Reconnect Only $ 63.00 $ 75.00 $125,00 $163.00 $375.00 $ 50.00 c. [TItnporary Services or_:F~deh -:--: -:-- _ __.__..".l...-_.~.____ --'~-', I Installation, Alteration or Relocation / so $ 50,00 $ 69,00 $100.00 200 Amps or less 20 I Amps to 400 Ainps 401 Amps to 600 Amps Over 600 Amps or 1000 Volts see "B" above. r-~--~~------- " .------- D. 1 Brii,ich <:ircu_its ~_;_ _~. . .. CJlJ TI'''' ....... New Alteration or Ext~nsion Per Panel f&4." I. . . One Circuit $ 43,00 Ai1v , . . .~'V"I E~olf'M.ditiJl!'al Circuit or with . , ,'b i_ ~ I ServicJl(1tJite~If~I-)' $ 3.00 Owners Name Qt_vd I..., Co L\1n~~ff.R.Oc.j\.. . I'S eERMl-f~ '.K _' ,~ Address ci.30 (0 <;~ c-r":llll~ I!;....t. . E. !~MiS~!Yl. 7i::i~'/fe.eder not incl~ded) ~E.ch Inst;'lIatiOl~ -..' rlY1h,."".r: " -~- CitySpl-tf,fe l..d Phone 141-25q4 P~mp oriiTigation $ 50.00 Sign/Outline Lighting $ 50,00 Limited EnergylResidential $ 25,00 Limited Energy/Commercial $ 45.00 Minimum Electric Permit Inspection Fee is $45.00 + Surcharges OWNER INSTALLATION The installation is being made on property I own which is not intended for sale, lease or rent. Owners Signature: .aJc;;?~p~ ~ ---- Inspection Request: 726-3769 4. (.SUnTOTALOFAliOvE L 1. -,- _,n - .~. .". -I ~-::'-,...-:.....:..--_._I 21> II.{ If( '2170 21.{ '7 ~ 7% Stale Surcharge 10% Administrative Fee TOTAL Shared Drive(T:)lBuilding Forms/Electrical Pennit Application 1-o3,doc I), , , \, ,/ " " . - . Construction Contractors Board 700 Summer St NE Suite 300 PO Box 14140 Salem OR 97309-5052 Phone: 503-378-4621 Web Address: www.cch.state.or.us Pennit#: c:.O>o\t,ce- 011.{ 77 ~~JC;c;,~ Issued by: 5731 cKcJ c+ Address: , Date: 11- II-D~ 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 permit 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 befiled with the permit. Fill in the 41'1"VI',;ate 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. o 3A. My general contractor is (Name) (CCB #) I will instruct my general contractor that all subcontractors who work on the structure must be licensed with the Construction Contractors Board. OR ~ 3B. I will be my own general contractor. If! hire subcontractors, I will hire only subcontractors licensed with the Construction Contractors Board. If I change my mind and hire a general contractor, I will contract with a contractor who is licensed 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 Property Owners about Construction Responsibilities on the reverse side of this form. ~~~5~ ---- .JO .-:2/. CJ::> (Signature of permit applicant) (Date) (White copy to issuing agency permit file, pink copy to applicant.) Property _ owner.doc 06-01-04 , .. . A~ttnnn~ till~ 1 @1lllIr (Q)wnn G~nn~Irtillll (DQ)nnttIrtill~tt@Ir? INFORMATION NOTICIC TO PROPERTY OWNERS ABOUT CONSTRUCTION RIESPONSIBILITIf2S NOTE: This Information Notice to Property Owners about Construction Responsibilities 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 being aware of the following responsibilities and concerns. JEmllDlliOiyeIr Re!lllDl[)lrrn!lnlblm~fie!l You will, in most instances, be ruled to be an "employer" and the contractors you contract with will be "employees" if you use contractors not licensed with the Construction Contractors Board to do labor in constructing or to assist in the construction or improvement of a residential structure. As the employer, you must comply with the following: Oregon's Withholding Tax Law: As an employer, you must withhold income taxes from employee wages at the time employees are paid, You will be liab]e for the tax payments even if you don't actually withhold the tax from your employees. For more information, call the Department of Revenue at 503-3784988. 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 information, call the Oregon Employment Department at 503-947-1488. The Oregon Business Identification Number (BIN) is a combined number for both Oregon Withholding and Unemployment Insurance Tax. To file for a BIN, call 503-945-8091 or www.dor.state.or.us/formsoav.htmll for the apJ-'..vp..~ate forms. Workers' Compensation Insurance: As an employer, you are subject to the Oregon Workers' Compensation Law, and must obtain workers' compensation insurance for your 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 employees is injured on the job. For more information, call the Workers' Compensation Division at the Department of Consumer and Business Services at 503-947-78]5, U.S. Internal Revenue 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 1-800-8294933 or visit their web site at www.irs.l!ov. O~lb1eIr Re!lllDl[)lilll"filbrfiHfi~fie" aIillirll Areas oj[ <COIillCeIl'illlS 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 attention through inspections. Liability and Property Damage Xnsurance: Contact your insurance agent to see if you have adequate insurance coverage for accidents and omissions such as falling tools, paint over spray, water damage from pipe punctures, fire or work that must be redone. Time: Make sure you have sufficient time to supervise your employees. Expertise: Make sure you have the skills to act as your 0\\'Il general contractor, to coordinate the work ofrough-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 CITY OF SINGFIELD SYSTEMS DEVELOPMEaORKSHEET JOURNAL OR JOB NUMBER: COM2005-01477 NAME OR COMPANY: Dale Prock LOCATION: 5739 Rid'?e Ct TAX LOT NUMBER: 1802041107100 DEVELOPMENT TYPE: SINGLE FAMILY RESIDENCE NEW DWELLING UNITS I BUILDING SIZE (SF: 2118 LOT SIZE (SF): 1. STORM DRAINAGF, DIRECT RUNOFF TO CITY STORM SYSTEM I IMPERVIOUS S,F, x I COST PER S,F, I CHARGE I 2920,50 I 50,323 = I $943.32 I RUNOFF ROUTED TO DRYWELL DESIGNED AND CONSTRUCTED TO CITY STANDARDS ! IMPERVIOUSS.F, I x I COSTPERS,F, I x I DlSCOUNTRATE I I I 0,00 I 50,323 I 50% I = ITEM I TOTAL - STORM DRAINAGE SDC $943.32 5179 tJJ W CI o U l:G ~ tJJ ~ " ~ DISCOUNT $0,00 $943.32 . 1070 2 SANITARY SEWER - nTY A. REIMBURSEMENT COST: ! NUMBER OF DFU's I x I 21 B. IMPROVEMENT COST: I NUMBER OF DFU's I x I 21 $19,07 ITEM 2 TOTAL - CITY SANITARY SEWER SDC COST PER DFU 525,07 $526.47 I 1091 $400.47 11092 = , $926.94 3, TRANSPORTATION A. REIMBURSEMENT COST: I ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEW TRIP FACTORI I 9,57 I I I $19.09 1.00 $182.69 11093 B. IMPROVEMENT COST: I ADT TRIP RATE I x I NUMBER OF UNITS I x I COST PER TRIP x INEW TRIP FACTORI I 9.57 I I I $84.19 1.00 $805.70 11094 ITEM 3 TOTAL - TRANSPORTATION SDC = , $988.39 J 4 SANITARY SEWER - MWMC I A. REIMBURSEMENT COST: INUMBER OF FEU's 1 x ICOST PER FEU I I I I 582.03 = $82.03 11054 B. IMPROVEMENT COST: I INUMBER OF FEU's I x ICOST PER FEU I I I 5865.31 = $865.31 1055 MWMC CREDIT IF APPLICABLE (SEE REVERSE) $0.00 1054 MWMC ADMINISTRATIVE FEE 510.00 I 1056 ITEM 4 TOTAL - MWMC SANITARY SEWER SDC =, 5957.34 I SUBTOTAL (ADD ITEMS 1, 2, 3, & 4) =, $3,815.99 J 5 AT1MINISTRATIVE FEE: I SUBTOTAL I x I ADM. FEE RATE. 1= CHARGE I $3.815.99 I I 5% $190,80 TOTAL SANITARY ADMINISTRATION FEE: 124,83 1079 TOTAL TRANSPORTATION ADMINISTRATION FEE: 565.97 1078 Cheryl Slaymaker 10/24/2005 TOTAL SDC CHARGES = $4,006.79 PREPARED BY DATE MWMC CREDIT CALCULA TION TABLE: BASED ON COUNTY ASSESSED VALUE I YEAR CREDIT RATEI$I,OO~ r ANNEXED ASSESSED VALUE IS LAND ELGIBLE FOR ANNEXATION CREDIT? 2 1- BEFORE) 979 $5.29 (Enler I for Yes, 2 for No) I 1979 $5,29 IS IMPROVEMENT ELGIBLE FOR ANNEX, CREDIT? 2 I 1980 $5,19 (Enter I for Yes, 2 for No) 1981 $5.12 BASE YEAR 1979 I 1982 $4,98 I 1983 $4.80 CREDIT FOR LAND (IF APPLICABLE) I 1984 $4,63 VALUE I 1000 CREDIT RATE I 1985 $4.40 $0.00 x $5.29 ~ , $0.00 I 1986 $4.07 I 1987 $3.67 CREDIT FOR IMPROVEMENT (IF AFTER ANNEXATION) I 1988 $3.22 V AWE I 1000 CREDIT RATE I 1989 $2,73 $0,00 x $5.29 O. I 1990 $2,25 I 1991 $1.80 I 1992 $1,59 TOTAL MWMC CREDIT = $0,00 I 1993 $1.45 I 1994 $1,25 I 1995 $1.09 I 1996 $0.92 I 1997 $0.72 I 1998 $0.48 I 1999 $0,28 I 2000 $0,09 I 2001 $0.05 225 Fifth Street Springfield, Oregon 97477 541-726-3759 Phone . a~~_~Nf:a.F1~ .____~ ~. Wit, .-.."-.: ! .-.I _. i1Iii1~Y of Springfield Official Receipt ~velopment Services Department Public Works Department RECEIPT #: 2200500000000001566 Date: 11/10/2005 2:00:57PM Job/Journal Number Description Amount Due COM200S-01477 Storm Drainage Impervious Area 943.32 c'OM200S-01477 Sanitary Sewer - Reimbursement S26.4 7 COM200S-01477 Sanitary Sewer - Improvement 400.47 COM200S-01477 SDC Transpo Reimbursement 182.69 COM200S-01477 SDC Transpo Improvement 80S.70 C.oM200S-01477 SDC MWMC Reimbursement 82.03 COM200S-01477 SDC MWMC Improvement 86S.31 COM200S-01477 SDC MWMC Administration 10,00 COM200S-01477 SDC Transpo Admin 6S.97 COM200S-01477 SDC Sanitary/Storm Admin 124.83 COM200S-01477 Building Permit 711.90 COM200S-01477 2 Baths One or Two Family 2S4.00 COM200S-01477 Furnace - up to 100,000 blu 12.00 COM200S-,01477 Vent Fan 18.00 COM200S-01477 Exhaust Hoods 9.00 COM200S-01477 Dryer Vent 6.00 COM200S-01477 Heat Pump 12.00 CbM200S-01477 -Mechanical Issuance Fee- 10.00 CbM200S-01477 Residence Wiring 1000 Sq Ft 106.00 COM200S-01477 Residence Wiring Ea Addtl SOO 57.00 COM200S-01477 Temp Power 200 amps or less SO.OO COM2005-01477 Plan Review Major - Planning ISO.OO d)M2005-01477 + 7% State Surcharge 86,51 CbM200S-01477 + 10% Administrative Fee 123,S9 CQM200S-01477 WiIlamalane Single Family 1,000.00 CbM200S-01477 Addressing Assignment 31.00 Item Total: $6,643.79 Payments: Cbeck Number Authorization Type of Payment Paid By Received By Batch Number Number How Received Amount Paid Check ORVILLE PROCK LKW S73 In Person $6,643.79 Payment Total: $6,643.79 ~; ., .' :\. , " 11/10/200S Page I of I