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Application Date:I SPRINGFIELD
225 Fifth Street,Springfield,Oregon 97477
Transportation&Engineering Section,Public Works Department I E_ . +t:
Permit Number I pw20 001.3az Phone: 541 726-3753 r`°T L ,r Ot y
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Issue Date: 's .' ' ' + OREGON
SITE INFORMATION t� _
Location ofWork:43, J 1 ,/•
Applicant:'5USC..YL to w � - RCVS Phone: l
Address: • ‘J ) I _���_2.�
Tax Map
City: 1 ' _ •State ipg,ZIP: °it,I Tax Lot •
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Subdivision
Owner: Phoned
Address:
City: State: ZIP:
REQUESTED PERMITS:
Fees
it Sidewalk Amount of sidewalk in excess of 90 feet $102.00 @$0.09 SF
Sidewalk Repair $18.00
[i Curb Cut/Driveway: Number of Driveways X$102.00 1st Cut X$54 2nd Cut
I-I Multiple Permit Discount each:(Maximum 2) $35
Multi permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
fl 5%Technology fee p ,
fll Proof of Insurance: $500,000 Minimum if work is done by property owner. Total due with permit$
CONTRACTOR'S
INFORMATIO
Name: I orThi,0851 Phon // I -6;69 _ I .
I
Address: � $1 9 Gross )
City: 14 fli(°. Stat R- ZIP:: x'1402
Contractor Registratio • I0 1 b • 1 Expiration date:
Project Supervisor IP A rs Ve, Phone:
INSPECTIONS:
An inspection request should be made prior to pouring concrete,after the proposed work has been formed and made ready to pour.
Curb cut and sidewalk inspections call: 541 726-3769(recording)State your designated City job number/permit number,job address,
type of inspection requested,and when you will be ready for inspection. Contractor's or Owner's name and phone number. Requested
received before 7:00 am will be made the same day,requests after 7:00 am 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.
You are required to call: The Lane Utilities Coordinating Council's"One Call Number" 1-800-332-2344,
48 hours before before digging.
SIGNATURE: