HomeMy WebLinkAboutPermit Sidewalk 2007-10-10
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,-<'.~', :'.';, DRiVeWAY/SIDEWALK" . 'PERMIT APPLicATION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
APPLICATION DATE: (li"tJ/J J)
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PERMIT NUMBER: ,t- 0 + ~,~o ~- b'~ :'J~
DATE ISSUED: . b Ifl Q
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APPLICANT
PHONE
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9JS- 6 'lePer
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PHONE:I c:r / S- - a '3 2 q
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ZIP:
SITE INFORMATION:
LOCATION OF WORK: / S' '"2 l...-(
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ADDRESS:
CITY:c5:P/l/~ 5r(c/p STATE
SUBDIVISION:
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ZIP:
CITY:
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OWNER:
ADDRESS:
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REQUESTED PERMITS:
o SIDEWALK: .........................................................................................$ 85,00 ..................,....... = $
AMOUNT OF SIDEWALK IN EXCESS OF 90FT. @$0.08 SF. = $
o SIDEWALK REPAIR:...................................,.........................................$15.00............................ = $
]if CURB CUT/DRIVEWAY: NUMBER OF DRIVEWAYS ,
,
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X .......................$ 85.00...1st Cut. = $~ . 1>....
o MULTIPLE PERMIT DISCOUNT EA: .........(MAX 2) ...........................$30.00, .. n Cut $ (
(MULTI PERMIT DISCOUNT GOOD FOR ONE SITE AND ONE SITE INSPECTION ..Dlli.Y
APPLIES TO 2nd AND 3,d PERM"S O'11,NOT SIDEWALK REPAIRl 2 d \ :$--
It 5% Technology Fee $ ~'Z.,. ~ . TOTAL DUE WITH PERMIT $ ke; " 1,.f('
o 'PROOF OF INSURANCE: $500,000 MINIMUM IF WORK IS DONE ~Y PROPERTYOWNEFi I
CONTRACTOR INFORMATION: I
CONTRACTOR:
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EXPIRATI0N DATE:
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AN INSPECTION REOUEST SHOULD BE MADE PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FO RMED AND MADE READY TO
POUR. CURB CUT AND SIDEWALK INSPECTIONS CALL 726-3769 (RECORDER) STATE YOUR DESIGINATED CITY'UOBI
NUMBER/PERMIT NUMBER. JOB ADDRESS, TYPE OF INSPECTION REQUESTED, AND WHEN YOU WILL BE READY FOR INS PECTION, CONTRACTOR'S OR
OWNER'S NAME AND PHONE NUMBER. REOUESTS RECEIVED BEFORE 700 A.M. WILL BE MADE THE 'i' .
SAME DAY, REQUESTS AFTER 7:00 A.M. WILL BE MADE THE NEXT WORKING DAY. INSPECTIONS ARE TO BE CALLED IN
AFTER EXCAVATIONS ARE MADE AND FORM WORK IS IN PLACE BUT PRIOR TO POURING CONCRETE. I.
YOU ARE REOUIRED TO CALL
THE LANE UTILITIES COORDINATING COU~JCIL'S
!lONE CALL NUMBER" 1-800-332-234.l
48 HOURS BEFORE DIGGING
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ADDRESS: ~;1 :? t7 ~
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CONTRACTOR REGISTRATION NO:
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PROJECT SUPERVISOR.
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PHONE: d cP S' "/$' 7 c;'
INSPECTIONS:
SIGNATURE:
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AMOUNT RECEIVED:
RECEIPT NO:
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DATE PAID:
RECEIVED BY:
By signa lure, I stale and agree, Ihall have carefully examined the compleled application and do he reby certify lhal all information herein is Irue
and correcl and f further certifY thai any and all work p'erformed shall be dane in accardance wilh the Ordinances of I
Ihe City of Springfield. applicaole City Standard specifications and DrawinQs, and the laws 01 the Slate of Oregon perlaining ta Ihe work described herein. , further
certify lhat .only contractors and employees who are in compliance wilh ORS 701.055 will be used \
on thiS proJecl.
The City may inspecllhe wark site described in Ihis permit at any lime during a .one year period fo 1I0wing the receipl by Ihe City of nolice of camplelion of Ihe
d~scribed vvork and.~pec;ify, <;I1.lhe City's sole discr!ltion, any (Idditional. resloration work reqUired to return th.e sile to a slaf]dard accep.table to Ihe Cily. The
permlnee Will be notllred In wnllng of any work reqUired and will have thirty days (30) from the dale ollhe notice to complete Ihe work. Work nol completed at the end
ollhe Ihirty days will be performed by tlie City and the costs will be billed to tlie permillee, ' (
I further agree 1.0 ensure lhat all required inspections are requested at the proper lime, lhal pra; ect address is readable from the
streel, and the appraved set of plans will remain on ~. e at all limes during construction. . . I
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Date
Signature
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