HomeMy WebLinkAboutPermit Encroachment 2000-2-11
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City of opringfield t,,_)
ENCROACHMENT PERMIT APPLICAT'ION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVIS/ON
OFFICE TELEPHONE (503) 726c3753
APPLICATION DATE: c2,-II- DD
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ENCROACHMENT .PERMII(J -~ /'""::) I
NUMBER: U() -(J ' 2 <.. ~ ""L/
DATE ISSUED:
LOCATION OF WORK
APPLICANT ..:.1 A C KL 0(,/ / ;=::
SITE ADDRESS: go1. 0 C e u i~" J 12 /fvdl.
CITY: !5fZtAJGF?EZP STATE: {}/2 . ZIP: C}7'1 71
SUBDIVISION: E. E kE;P/JE1(51. i!r 7JDITlO;J
OWNER: J it C Ie LOU; r
8 Z 0 Ce,1,{!&f.u~
PHONE
.6-7 q - 'If:] :s 7
TAX MAP: /7, 0 ~ .:J.G. tv 3
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TAX lOT:
PHONE:
571'-Lf537
ZIP: 91lf 77
. AODRESS:
CITY:
S/Jt~4r4rcrL~cf
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STATE: (!)R.
CONTRACTOR:
ADDRESS:
PHONE:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
EXPIRATION DATE:
PHONE:
REQUESTED PERMITS:
INSPECTIONS REQUIRED:
APPLlCptON'FEE/'BFPOSIT
,,',;$'80,00/ )
ACCOUNT NO:
o EN,CROACHMENT PERMIT NO: ....~........................... (V'I
ao. ()()
VALID FOR SIXTY 160) DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
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o
o DUST CONTROL (TYPE OF CONTROL)
o CONSTRUCTION, STORAGE, STAGING
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o
o OTHER
o AS'PHAL T DEPOSIT.."..."..."",..,.,.".""",..",......"",."."...",..".,."..,.",.....,..".., ,..""."..,'... $
D TYPE OF SECURITY QEPOSIT For:
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH 1 CHECK $
D SANITARY SEWER CONNECTION': ...... Ef~AIN LINE (EASEMENT,R/W) 0 TO STUB. D.()THER
D STORM SEWER CONNECTioN: 0 CATCH BASIN 1 BUBBLER 0 STUB 0 MAINLINE
D PROOF OF INSURANCE: $500,000 MINIMUM 0 ATTACHED 0 ADDITIONAL REQUIRED AMOUNT
. TOTAL DUE WITH PERMIT $
00,00
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETS) ATTACHED
AREA: LENGTH: WIDTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MixT~RI'AL': '
BACKFILL MATERIAL TO BE UTILIZED:
FROM DATE:
TO DATE:
DEPTH:
TIME:
TIME:
HEIGHT:
BORE:
BACKFill MATERIAL:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONl!ROl TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED: .' f
Advance signing and work zone protection to be in compliance with the Manual on Uniform Traffic Control Devices (MUTCD ~
" DESCRIPTION:
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVI,\>IONS 3/29/99
FORM # 11 6
PLAN REVIEW COMMENTS / SPEC INSTRUCTIONS:
RESTORATION WORK SHALL BE IN CONFORMANCE WITH EXISTING CITY CODES AND IN cOMPLIANCE WITH CURRENT
STANDARD SPECIFICATIONS. EXCEPT AS NOTED BELOW. '.
O 001 D 019 Minumum 4' .::Iearance at any point,' sWing',away.
Backfill with '10" minus Tock.
D 002 D 020 Concrete minimum 4" depth, 3,000psi.
Compact every 16" loose depth, 0
D 003 Requires compaction with a steel roilier. 021 Trench to be liT" cut.
004 D 022 Needs State / County permit,
o A.C. to match the greater of existing depth or 4".
D 005 0 023 No above ground enclosings in aidewalk or hendicap ramps.
All cuts sealed for final inspection.
O 006 0 024 Diamond cut A.CJConcrete value boxes to grade.
Temporary patch may be used at the end of the day.
D 007 0 025 Fresh Oil signs / Graded.
Signing and Zone protection to comply with MUTCD
n ' O()ll 0 026 Comply with Americans with Disabilities A, ct.
1...1 '" Cut CgnCfllle only on 6GOfe IinelJ or cold jPintli, 0
o 009 Sidewalks and driveways min. 3,000psi. 027 Concrete Blabs, 72hrs. curing time, 4500psl.
D 01 0 D 028 Concrete slabs require joint seal material.
Curbing min 3,500psi / No patchwork less than 3'.
o 011 Meet min, requirements on curb cuts, Spfd. code. 0 029 Driveway requirea dowels every 18".
D 2 D 030 Submit traffic control plan prior to excavation.
01 Restore planted areas, Spfd, code 206,3.05
3D 031 Notify Traffic Division before excavation,
o 01 Spec, to Bore / Jack / No A,C. cuts.
O 0 032 Core drill main line, insert tee, 2% min. grade.
014 Mechanical compacting required. .
o 015 No patchwork allowed, 0 033 Must comply with the provisions of ORS 757.541 to
757.571.
o 016 Lateral cuts to have control density fill. 0 343 6" Circular hole/H20.Vac.
o 017 Cuts to be polymerized crack sealed for final inspection, 0
o 018 Mininum 2" crushed rock '10" minus. '
Comments:
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
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o CURB CUT AND SIDEWALK INSPECTION CALL 726-3769 (REC RDER) STATE YOUR DESIGINATED CITY JOB
NUMBER/PERMIT NUMBER, JOB ADDRESS, OF INSPECTIO REQUESTED, AND WHEN YOU WILL BE READY FOR
INSPECTION, CONTRACTOR'S OR OWNER'S NAM ! NUMBER. REQUESTS RECEIVED BEFORE 7:00 A.M. WILL BE
MADE THE SAME DAY, REQUESTS AFTER 7:00 A.M. WI L tlc 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.
D SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
726-3761.
SIGNATURE: ~.. G1-~
U
AMOUNT RECEIVED: 4106,00
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RECEIPT NO: S I -'"
DATE PAID:
RECEIVED BY:
2f0 / nO
f-r<j Jt /1
L'" - '-''vI.
By signature, I state and agree, that I have carefully examined the completed application and do hereby certify 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 City Standard specifications and Drawmgshand the laws of the State of Orejlon pertaining to the work
described herein. I further certify that only contractors and employees w 0 are in compliance with ORS 701.055 will be used on this
project. ' , .
The City may inspect the work site described in this p'ermit at any time during a one year period following the receipt by the City of
notice of completion of the described work and speCify, at the City's sole descression, any additional restoration work required to
return the site to a standard acceptable to the City. The permittee 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 ena 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 street,
and the approved set of plans will remain on the site at all times during construction.
Signature
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Date ~//;/ OD
VALIDATION:
D TRAFFIC REVIEWED BY:
D ENGINEERING REVIEWED BY:
D MAINTENANCE:
D PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
FOR SIDEWALKAND CURB CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT ORA WER.
INSPECTION: DATE:
INSPECTION: DATE:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DATE:
DATE:
DATE: