HomeMy WebLinkAboutPermit Encroachment 1998-3-2
1 225 FIFTH STREET' '....
SiRINGiijELD. OREGON 97477
ENGINEERING DIVISION ' ,
OFFICE TELEPHONE (503l 726.3763
~
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"',~ (. " ....':;.~~. ~:;.' ! . r.-: ~.l ~~
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE '
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: 9 ~a::> 2-5"4-
~l2 /'5'i8
'. -, ,
,.LOCATIONOFWORK ,2.z.~ A S
APPLICANT jdAJ'A*i"'''Ie:t'{1 Ifnt<~ ~ .
SITE ADDRESS: '2 '2. ~ A S / ~
CITY: 1~~ STATE: /11<
SUBDIVISION:
OWNER:
ADDRESS:
CONTRACTOR:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
APPLICATION DATE:
DATE ISSUED:
/
PHONE 7~L - p;,~S /
TAX MAP: /7n'?:l S .2. '-
ZIP: <;' ?fL7;J TAX LOT: / A/ ~
CITY:
ADDRESS:
PHONE:
STATE:
ZIP:
PHONE:
EXPIRATION ,DATE: '
PHONE:
REQUESTED PERMITS:
MPeCTlONS REQUUWh AMJCATION FEll ouoarr
ACCOUNT NO:
Q ENCROACHMENT PERMIT NO: ............................... n
VALl) FOA SlXTY fSOJ DAY'IROM DATI 0fI1SSUANC1
o CUT STR~~T 0 BORE 0 OTHER Q
o DUST CONTROL (TYPE OF CONlllDIJ
. '
Q $20.00 I
0$
o CONSTRUCTION, STORAGE. STAGING
QOTIIER
n
n
0$
0$
0$
Q ASPHALT DEPOSiT.........................................................,..................................................
. . . .
mE.,tlF ,C;Fr:lIRITY D!;POSIT
Q BLANKET SURETY BOND " Q SURIITY 80ND Q CASH I CHECK
o CURB CUT PERMIT NO: :...~.......~...:... FT. n
",..HM1f'lN. CURl / APft!lOAat AFRR FORMS ARt WCTID BUT PIUOR TO POURlNCI CONCRETE.
, VAl.DI'O.'IODAV.,.OM DATlCll'IPIIANCL
C SECOND DRIVEWAY (SEE SEPARATl! AI'Pl.ICATlONl
o SIDEWALK PERMIT NO:.................... FT. <P f9f 0 $10.00H.161FT.
VALIO,.,O teoOA.IMOM OATlO'ISIUANCL W e.~Id8' JPIIJT
o NEW Q REMOVE I REPAIR Q PAVE PLANT STRIP /)/EiliP/N)Ui" ~ I9G" ""'^
o 'SETBACK (lj{CURBSIDE QLENGTH ~ O,QIl.L~v
1~!::_t"Tlf'lN. RtDEWAl,K, DRNIWAY FOR AU. CONCRITI PAVING WITHlN THE STRUT RIGHT 0' WAY. TO Sf
MADI AfTtA ~ IXCAVA,11KG 1& COMPUtE. AND FOAM WON. AHO SUI-IA.SI MATINA1. II IN PLACI.
o SANITARY SEWER CONNECTlON.PERMIT:................n
VALl) POR SIXTY tIC>> DA.YS FROl.l DATI OP Ga\WCI
o TO STUB 0 MAIN UNE lEASEMENT.R/Wl Q OTHER
o STORM SEWER CONNECTION PERMIT: .,.................. n
VAl.D "'01lXTV 1001 OAVlMOM DATI 01' IIIUANCI
o CATCH BASIN I BUIlIlLER 'C STUB C MAlNUNE
f.BJl"c "c '''lSIlRANCE' $600,000 MINIMUM
, C ATTACHED Q REQUIRED AMOUNT
0$
o $tO.00H.151FT.
10,'0
o $6.00 I '
0, .6.00 I
TOTAL DUE:-.
TOTAL DUE WITH PEAM!T,.
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETSl ATTACHED
AREA: LENGTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED:
TYPE OF OUST CONTROL TO BE UTI~IZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
Advonce olgnIng ond _k lOllO ,llIOtoctlon to be In colllllllanco wlllllllt Manual ~ Unit.... TraUlc Control DoYle.. (MUTCD),
FROM DATE:
TO DATE:
WIDTH:
DEPTH:
,TIME: '
TIME:
. HEIGHT:
BORE:
BACKFILL MATERIAL:
DESCRIPTION:
;
WORK SHALL COMPLY WITH CHAPTER X ARTICLE II OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .'
RiVlSIOHS 8124185 FORM , III
,
PLAN REVIEW COMMENTS I SPE~>>pNSTRUcnONS: , .. '
D,1t<<b'A1t'B~~~~r~AW~,BM~_~CIEY:'6W. EXISTING CITY CODES ANdW'c.'bMPUANCE WITH CURRENT
~ 001 Bock"" With.' mlnUl rock. " ~ 018 M1numum 4' cl""nc, ,tiny pOlnl, "wlng,"woy, ..
002 C.mp.ct,.,ry 18.1.... dopth. ' 020 C.ncr'lI minimum 4' d.pth, 3,OOOpol.
. 003 R.qul'lI completion with . .tll' rollllt. 021 TrenCh to be ! cut. .. .
004 A.C.I. motch tho g...tor.' ,xlotlog d,pth.r 4', _ 022, Naod. St.to t CounIY permit.
: .005 AD outI ,"l.d for tlMI fnapio.don. . 023 No ,bOW ground .ncloalngt In .Idew.lk or hlncUc.p ramp..
_ 008, TompOllry P'lch may ba Ulod .1 tho end 01 th, doy. _ D24 Dlomond CIlI A.C./COncral' .olu' boxoo t. grado,
. 007 Signing .nd 20M Proloctlon 10 comply with MUTCD _ D25 FrIO. 011 .Igna , Oradod.
_ 008 CUI concrot, only on ICO.. Ilnoo 0, .old lolnu. ' _ D28 C.mply With Am,rlca.. With OlooblllUoo Act.
_ 008 Sldowllka .nd driV,w.y, mln. 3,OOOpo~ , _ 027 ConcrOIl oI.b., 72hra. curing tlm., 4500ll01.
_ DID Curbing mln"3,800llol' No potchwOltc 'aollh.n 3'. _ 028 C.....t, ol.ba raqul',-I.lnl.aol mal.rlal.
_ 011 MlaI min. raqulram'nII on curb out., Spld. cod,. _ D28 Drlv,way raquln. dowel. ,,'ry 18'.
_ D12 R.otora plontod""", Spld. cod, 208.3.<15 _ 030 Submit I"Ino control pl.n prlorto ..c..oU.n.
013 Spac. to B... , Jock t No A.C. CIlI.. ~. D31, ~.tlly Tralflo Dlvlalon balore ,xco.otlpn,
~ 014 Mochonlcal comp.ctlng raqulred. 032 Cor, drlD main 1In" lnaorl lao, 2% min. 8redo,
D15 No patchwork .Dow'd. 033 MUlt comPly with tho provlolona of ORS 757,541 t. 757.571.
, D18 Lalo..1 CUll to ho.o contrOl donalty nn. 343 8' C1rculor .0,,/H2o-Voc.
017 CUll 10 ba polymorlzod creck .aolod lor IIn.t' Inopoctl.n. _
,018 Mlnlnum 2- crushed rock J. mlnut.
... ..1..
...
COl)'lments:
.
.,
YOU ARE REQUIRED TO CAll
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" '-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
'Q
CURB CUT AND SIDEWALK INSPECTIONS CAll 728-3789IRECORDER) STATE YOUR DESIGINATED CITY JOB
NUMBERIPERMIT NUMBER, JOB ADDRESS, TYPE OF INSPECTION REQUESTED, AND WHEN YOU WILL BE READY FOR
INSPECTION, CONTRACTOR'S OR OWNER'S !'lAME AND PHONE NUMBER. REQUESTS RECEIVED BEFORE 7:00 A.M. WILL BE
MADE THE 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 WOFjK IS IN PLACE BUT PRIOR TO POURING CONCRETE.
o SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
728.3761.
SIGNATURE:
AMOUNT RECEIVED:
RECEIPT NO:
90'"
/.Q,
Z~95"S-
"';"'1-
DATE PAID:
RECEIVED BY:
3/ .z.../?t::.
f~L
. '
By signature, I atate and agreefi that I have carefully examlped the completed appllcetlon and do hereby certlfv that all Information
haraln la true and correct, apd further certify thet any and all work parformed shall be dpna In accordance with the Ordinancas of the
, City of Springfield, applicable Itv Standard apeclflcetlons and Drawlngshend tha laws 01 tha State of Orejl~on pertaining to the work
described herein. I further cert fy that only contrectors and emplDyeas w 0 are In compliance with ORS 701.055 will be used on this
, project,
The City may Insllect the work site described In this Ilermlt at :any \Ime during a one year period following the receipt QY tha City of
notice of, completion of the described work and ,peclfv, st the City a aole descres,lon, apy addltlonel restoration work re~uirad to
, raturn th, ,Ite to a stendard acceptebla to tha City. T1ie permittee will be notllled In writing of any work required and will have thirty
" daYS (30t,!rom the dele ofb ttha .nOtllhCB to col'/1plete the work. Work not completed et the en(J of the thirty deys'wlll be performed by tha
City and ~,e oosts wll be ,lIIed to e,permlttee.
" I furthor egree to ensure that an required Inspections are requllsted et the propar tlma, that project eddress Is readabla from the streel,
and the approved set of plans will remain on the site at all t.mea during construction.
.,' .
Slgnatura;(~)' VJt ~~ Date -:3/ ~/9 y
f ' 'f
VALIDATION: v
o TRAFFIC REVIEWED BY: DATE:
~ ENGINEERING REVIEWED BY: P-:r.Ix. ~~ DATE: 0/S-8
o MAINTENANCE: DATE:
, 0 PERMIT ISSUED BY: ' .~ DATE: ~/rfb
. FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT DRA WER.
, INSPECTION: DATE:
:, INSPECTION: DATE:
, WORK IN PROGRESS DATE:
AT TIME OF COMPLETION: DA T~:
ELEVEN:rH MONTH: ' OA TEl
DEPOSIT RETURNED: DATE:,'