Electrical Permit ApplicationDepartment of Consumer & Business ServicesBuilding Codes Division· Lake County Contract Office .513 Center St., Lakeview, OR 97630(541) 947-6033, Fax: (541) 947-2144Web: bcd.oregon.gov

This permit is issued under OAR 918-309-U000. Permits are nontransferable. Permits expire if work is not started within 180days ofissuance or if work is suspended for 180 days.

Job site address:

City/State/ZIP:

Project name:

Directions to job site:

Subdivision: Lot no.:

.Number of inspections per item ( )

7011111195 (A) Enter total of above fees

p;106.00

Residential, per unit, service included:

Items Cost ea. Sum

1,000sq. ft. or less (4)

201 to 400 amps (2) $86.00401 to 600 amps (2) p;125.00

$19.00$25.00

Each additional 500 sq. ft. or portion thereof

$63.00

Miscellaneous: (service or feeder not included)

Each pump or irrigation circle (2)Each sign or outline lighting (2)

Limited energy (2)Each mmufactured borne or modulardwelling service or feeder (2)Multifamily residential (1) S45.00Services or feeders: (installation, alteration, relocation)

200 amps or less (2) :} $79.00 IISr3 ' 2-201 to 400 amps (2) $94.00

~.!52..~~Xl1JU¥-lLJ,,~:>L.:~d..J<!,~~~.L..:::~~~~~~~]\. 401 to 600 amps (2) )156.00601 to 1,000amps (2) p;204.00

Name:

Address:

CitylStatelZIP:Phone: ( ) Fax: ( )This installation is being made on residential or farm property owned byme or a member of my immediate family. This property is not intendedfor sale, exchange, lease, or rent. ORS 479540(1) and 479.560(1).

~ion hp.Tp,,:

Carl Tracy Electric LLC.P.O. Box 1093Lakeview Oregon 97630PH. 541-947-2216--Fax 541-947-2661CCB--169846 BCD--C174

CCBlic.:

Signature:

Over 1,000amps or volts (2) js469.00Reconnect only (2) / $63.00

$63.00$63.00

S63.00

Temporary services 6'r feeders: (installation, alteration, relocation)

200 amps or less (2) $63.00

Signal circuits(s) or a limited-energy panel,alteration, or extension (2)

Hourly rate (number of hours) 11 $86.00

70111/1291 (B) Enter 12percent surcharge (.12 x [AD

I~~~~~~J3USINESS\)LSERVICES

44O-2584--LKCC (1/06lCOM/WEB)

Over 600 amps or 1,000volts. See services or feeders section, above. "Branch circnits: (new, alteration, extension per panel)a. Fee fur branch circuits with purchase of a service or feeder fee:

Each branch circnit -z... $4.00 'bOV

b. Fee for branch circuits without purchase of a service or feeder fee:

First branch circuit (2) $54.00

Each additional branch circuit $4.00 "

7011111195 (C) Plan review, ifrequired (.25 x [AJ)

TOTAL fees and surcharges:

DCBS fiscal use only:

If paying by credit card, applicant 'box. Do not send cash. Each additional inspection: (1) S55.00

/6bo Visa o MasterCard o Discover Phone: ( )

I

Credit card number ExpiIation

Name of cardholder as shown on credit card

$Cardholder signature Amount

, "

".

~ Lake County Building Department/ . 1-~~;/4<~) 513 Center Street (541) 947-6033~-"--<:-/ / Lakeview, OR 97630 (541) 947-2144 fax

ILAKE COUNTyl-, INSPECTION REQU!iST

~5EEVrcL~Date requested: 8)2 :20 I) I Time: Type of inspection: ELEel--r-- J./11 .•.. - )qJ-.j 7- :;2~/ bOwner.j-,' 0 HI ...••. -J-r/ / Phone: (.5 L/ /

)5Electrical o .I / 0 Str~ctura'l o Mechanical o Manufactured homePlumbing

Permit no.:£::LI/ Lf!090 I Requested by: f7.,4 LL I Contractor: ( ~£L I/2ACL-I/~7oo9 ' I . ~rC);JE -;?;~KFVz-£"u) /Job address: CuJ-.!oU,lCi

/ / )Directions: / /

,

Ready (date): g/ ;;L/ 'd--O I / o Mon. o Tue. OWed. ~Thu. o Fri. o A.M. o Mid o P.M.. I N / \

Call before cormng? . 0 0 DYes Phone: ( )INSPECTION REPORl .~.

Date inspected: ~·A lAG- .~-1'ime: Type of inspection: ~'-I \0;:::::o Unable to inspect ~o corrections noted-- -'\ o Correction(s) expected within days

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Inspection report no.:~------ .---/ o Correction(s) noted: (Page of )

,

,

,

o Reinspection required prior to approval o OK to continue after corrections madeo Owner/contractor must sign below to indicate all corrections are made; return form to inspector.

Owner/contractor signature:

o Call for reinspection ....-.--Inspector signature: -tt-Inspector name: \~

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