HomeMy WebLinkAboutPermit Application 1995-9-6
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Oregon
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DEPARTMENT OF
TRANSPORTATION
September 6, 1995
DistrictS
FILE CODE:
C & E Rentals
ATTN: Scott
1570 South A ST.
Springfield, OR 97477
Enclosed is an Application to Perform Specified Activity within State Highway Right of Way.
THE APPLICATION IS NOT A PERMIT, .
Please sign the application in the box marked APPLICANT and fill in the date space.
Any of the items checked below will also be required.
(X) insurance
( ) Perfonnance bond in the Amount specified on form. (form attached)
(X) Administrative fee in the amount of$ 50.00 . Make check payable to the Oregon
Department of Transportation.
(X) Signature oflocal government official
Ifinsurance is required you will need to provide the Oregon Department of transportation with
an insurance certificate nammg the denartment as additional insured. The
Sincerely
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Michael J. Barker
Permit Specialist
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734-2257 (4-92)
3620 Gateway
Springfield, OR 97477
(503) 726.2552
FAX (503) 726,2509
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~.",~"",o HIGHWAY DIVISION
HIGHWAY NAME
McKenzie
.APPLlCATION AND PERMIT TO _
CONSTRUCT APPROACH ROAD
PERMIT NUMBER
MILEPOINT
I
ENGINEERS STATION
15
I COUNTY
Lnne
2.64
SIDE OF HIGHWAY
o NORTH 0 EAST
o SOUTH 0 WEST
HIGHWAY REFERENCE MAP AND ATTACH
80+20
APPROACH TO SERVE
HIGHWAY NUMBER
BETWEEN OR NEAR LANDMARKS
Rental Business
o DRAWING NUMBERS
15th St
AND
17th St
5B-36-8
BOND REQUIRED
AMOUNT OF BOND
APPLICANT NAME AND ADDRESS
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REFERENCE
o YESXX NO OAR 734-50-025(6) $
I INSURANCE REOUIRED
REFERENCE
.DYES 0 NO OAR 734-5Q.025(3)
I AMOUNT
$50.00
1 ~STRICT MAINTENANCE SUPERVISOR OF REPRESENTA liVE
I ~EGION ENGINEER OR REPRESENTATIVE
UTILITY PERMIT SUPERVISOR
o
I C&E Rentals
1570 South A Street
Springfield,OR 97477
'I
Xl ADMINISTRATIVE FEE
o TEMPORARY DEPOSIT
CHECK NUMBER
DATE COMPLETE
APPLICATION RECEIVED
L
DATE
APPROVAL DATE
TELEPHONE NUMBER;
x
APPLICANT
I APPLICATION DATE
SPECIFIED COMPLETION DATE:
REFERENCE: OAR 734-so.050(4)
Q-JC1-Q';
x
The eppllcant declarel that he/she Is the owner or lessee 01 the real propertr. adlolnlng the above described highway and has the lawful authority to apply lor this permit. When this
application Is approved by the Department 01 Transportation, the applicant s subject 10 the terms and provisIons contained hereln and attached hereto: and the terms 01 Ore~on
Administrative Rule, Chaplar 734, Division 50, which Is by this relerenca made II part of this permIt. Copies 01 the Rule may be obtllined from Ihe District Malnlenance Supervisor's
olllce.
Issuing 01 permits under these regulations Is not a Ilndlng of compliance with the statewide planning goals or the acknowledged comprehensive plan lor the area. Permits are Issued subject
to the approval 01 city, county or other governmentalagencles having either Joint supervision over the section 01 highway 0( authority to re!:lulate land use by means 01 zoning and/or
building
reguletlons. II shen be the applicant's responsibility to obtain any such approval including, where applicable, local government determination 01 compliance wilh the statewide planning
goals. (OAR 734.5().{l55)
SPECIAL PROVISIONS
1 - If the proposed application requires traffic control devices and/or special road construction, the applicant shall provide a copy of this application to the
~ocal government. The original application must be signed by the local government official.
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2.L Within 48 hours b~~~~ ork and after completing the p mlt work, the applicant or hIs c~ntr8ctor shall notify the District Representative at
telephone number -
Approach to be reconstructed to ADA standards and City of Springfield standards.
This permit canccels and supercedes permit D 14824.
TYPE 4 APPROACH ROAD - CURBED HIGHWAY
NOTE: All material and workmanship shall be in accordance with the cur.
rent State of Oregon Standard Specification for Highway ConstructIon.
R/W L1n_,-,
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Drwy.
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30'
W,- 36'
APPROACH TYPE
A
x- 4'
CURB TYPE
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I ANGLE OF SKEW
90
A
NOTES:
W - WIOTH OF ORIVEWAY
K - DISTANCE FROM FACE OF CURB TO BACK OF
PRESENT OR FUTURE WALK OR 10 FEET.
WHICHEVER IS LESS
W, - SEETABLEAON REVERSE
X - SEETABLEAON REVERSE
734-3307E (&-88)
SEE BACK OF APPLICATION
produeed by STATE PRINTING