HomeMy WebLinkAboutPermit Curb Cut 2000-8-4
c .. 1";' .
'City of Springfield .j
DRIVEWAY/SIDEWAL PERMIT APPLICATION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
~
PERMIT NUMBER: 00 - ()l \~'O -0)
DATE ISSUED:
APPLICATION DATE:
SITE INFORMATION:
LOCATION OF WORK: 1/:) J};:; r3Pi?JAJ6FIEii)
APPLlCANTI2'<f6fJ;JCoUf).}--r:i(<I r:tiN.5r,
, ADDRESS: 8c;;]11J (Jl.1J C~IJt(I<G?/)
OJ!
PHONE C>81- or:1 / q
CITY: E1,cuF'
SUBDIVISION:
OWNER: k#::J()1:) ,
STATE: n~
ZIP: 9'110 F3
TAX MAP: I1tf2,'l.c::~L-
TAX LOT: "01
;:;; J.. ) tI7< In,
!-/v M e
PHONE:
STATE: !b
ZIP: 911'11
ADDRESS: Lid JJ :JT
CITY: ~/J-btJtct-D
I 1/
REQUESTED PERMITS:
i:I DRIVEWA Y /~RB-CU~IDEWAlK)w, ,,,w,,,, ""~""" "" "'"'' "'",,,''' ,,,.,, ."" ,,"""", $ 60,00
AMMOUNT OF SIDEWALK IN EXCESS OF 90FT, @$0,06 SF, $
o SIDEWALK REPAIR: """."'"'''''''''''''''''''''''''''''''''','''''''''''''''''''''''''''''''''''''$ 10,00,
o ADDITIONAL DRIVEWAY: """,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$ 30,00
o PROOF OF INSURANCE' $500,000 MINIMUM IF WORK IS DONE BY PROPERTYOWNER
TOTAL DUE WITH PERMIT $ j, 0 ' 6D
CONTRACTOR INFORMATION:
CONTRACTOR: ~"::'nM rn~ ~'1 0(")0<;/,
ADDRESS: lFt'1/h nZf) QDt'Ulb l(j) ,Eu~IJC: (~
CONTRACTOR REGISTRATION NO: t:,4()f:X~ .
PROJECT SUPERVISOR: ~~.ui'" J-;::-~
PHONE: $'J-@/(j
EXPIRATION DATE:.liJ,- O,.j
PHONE: /i!1-5,f) 1-'1 "/ I')
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 726-3769 (RECORDER) STATE YOUR DESIGINATED 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 REQUESTS 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 REOUIRED TO CALL
THE LANE UTILlTIES.COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE: '
AMOUNT RECEIVED:
RECEIPT NO:
DATE PAID:
RECEIVED BY:
By signature, I state and agree, that I have carefully examined the completed application and do hereby certiN that all information herein
is true and correct and I further certify that any and all work performed shall be done in accordance With the Ordinances of
the City of Springfield, applicable Citr Standara specifications and Drawings, and the laws of the State of Ore.!lon pertaining to the work
desc(ibed ~erein, I furth~r certify tha only contractors and employees who are in compliance with ORS 701.055 will be used
on thiS proJect
The City may inspect the work site described in this permit at any time during a one year period following the receipt by. the City of notic"
of completion ofthe described work and specify, at the City's sole descression, any additional restoration work reguirea to return the silt:
to a standard acceptable 10 the City. The permitlee will be notified in writing of any work required and will have thirty days (30) from the
date of the notice to complete the work, Work not completed at the end of the thirty days Will be performed by
the City and the costs will be billed to the permittee, .
I furthor agree to ensure that all required inspections are requested at the proper time, that project address is readable from the
st~eet, ana ~o~set ~Ians will remain on the, site at all times during construction, ,
Signature ~ k 'V"j 4$';/ -. Da~:_m~i2_ _~, r!)OOU