HomeMy WebLinkAboutPermit Encroachment 1995-12-28
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' ;CITY OF SPRINGF: ~LD .' . ~~.UJIIT APPLlCA T~dN
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726.3753
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ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: f!!} 95' /7oe;-O
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INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
APPLICATION DATE: /2 -Zg-P5
DATE ISSUED:
a
LOCATION OF WORK
APPLICANT ~ ('f-lr=-~J _ PHONE (/') 9/1~ 77/:'"2--
SITE ADDRESS: .:i:.a. - ~_::#-::-' ::_ ....f_ ~, -,77~'t "'-"''Q-~~X MAP: -/2/;'2.. F./aL1
CITY: t;;(,l?-' STA~E:, o/l-- . ZIP: 9NIJ'2- TAX LOT: 9?tJO
SUBDIVISION: I v~ff.,; /../~t'f''I' JJo/7/t!!?)
L..1E0/)~-r/) -q.,iWAfi:t?
ADDRESS: ?5"tt Af::{ lo-rr LJ.{ CITY:~eCc. STATE:
CONTRACTOR: f tJ:f'dl tfl~l- ADDRESS: /44/ ;.}W'; '19' /I
CONTRACTOR REGISTRATION NO: r;,~ L.fC.I7 EXPIRA TION DATE: < _tp(~
PROJECT SUPERVISOR: 'f}o-~ ICrI/E.r32-L
OWNER:
PHONE:
. Oil
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ZIP: C; 742h
. (c89 ...;
PHONE: -771;,7
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REQUESTFn PERMITS: rNSP<CTrONS REourRED:
I3'1N~RO~-C~MENT PERMIT NO: ............................... ~
o CUT STREET 0 BORE 0 OTHER 0
o DUST CONTROL ITYPE OF CONTROLI
o CONSTRUCTION. STORAGE. STAGING n
o OTHER "
o ASPHALT DEPOSIT...... .... ............ ....,........... ...................... ...................... ................ m.....
TVP~ n~ ~~r:lIRITV n~PflSlI
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH / CHECK
o CURB CUT PERMIT NO: .................... FT. 0-
rN~pl=~T1m... CURB I APPROACH AFTER FORMS ARE ERECTED BUT PRIOR TO POURING CONCRETE.
o SECOND DRIVEWAY ISEE SEPARATE APPLICATION)
o SIDEWALK PERMIT NO: ..,................, FT. n
PHONE:
h<'61..::..7 '1(P2
APPliCATION FEE I DEPOSIT
ACCOUNT NO:
EJ"12'0.00 /
0$
0$
0$
0$
0$
o $10.00H.15/FT.
o NEW 0 REMOVE / REPAIR 0 PAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
rN(;~rTlnN. O:::IDEWALK /DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
.......... ~E AFTER All EXCAVATING IS COMPlETE. AND FORM WORK AND SUB-BASE MATERIAL IS IN PLACE.
~ SANITARY SEWER CONNECTION PERMIT: ..........,..... n
~ '_/"'. "
It:JTO STUB 0 MAIN LINE (EASEMENT.RIWI 1:::f0THER ~f'c... Y I r, D
o STORM SEWER CONNECTION PERMIT: .............,..,...fl
o CATCH BASIN I BUBBLER 0 STUB 0 MAINLINE
PROO~ OF INSURANCE. $500.boo MINIMUM
o ATTACHED 0 AMOUNT
o $10.00+$.15/FT.
~O/
o $5,00/
TOTAL DUE: $
TOTAL DUE WITH PERMIT $
.:7 c;- d ()
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DESCRIPTION OF PROJECT:
PERI~OF USE OR TIME OF CONSTRUCTION:
~LANS (TWO SETS) ATTACHED
AREA: LENGTH: WIDTH:
TYPE OF WORK: CUT:
OTHER: {]tJIJJJ,Pt!..-r
FROM DATE:
TO DATE:
J~ -::d.--crh
'il - ~/- t?~
DEPT1:
TIME:
TIME:
HEIGHT:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED:
BORE:
Y f,c.o, '
-Z;;;;:VIl-?'. tf_ C;-rv.$ /,.;'
/! / k:J' BACKFILL MATERIAL:
..;. ~ ,
RiV -
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TYPE OF OIL (STREET OILING ONLY) TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
Advance signing and work zone protection to b~'in compliance Wltn the Manual on Uniform Traffic Control Devices (MUTeD).
"volf..../. ,
DESCRIPTION: (lo/..tIJt:~..,. I ~"..I ~nu AOr AJ../O e.'i.-r~~ r. PJ?./JPIiU-rV /1./ PI.LJf-
("'-11.$ fAO~"'" /~ A "/Vl1tu "'..I.N~. ~~_ fl.QJ.J A-r-f'VJ.I.I'.,o.
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE, CONTRACTOR TO COMPLY WITH MUTCD .
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REVISIONS 8124195
FORM # XXX
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PLAN KtVIl:W <.;UIVllVltN I:; / :;t-'l:l,;II-\L II~:; I KUl,; IIUIII:;:
RESTORATION WORK SHAll BE IN C.RMANCE WITH EXISTING CITY CODES A. COMPLIANCE WITH CURRENT
STANDARD SPECIFICATIONS, EXCEP NOTED BELOW.
. 001 Backfill with~" minus rock.
. 002 Compact every 18" loose depth.
. 003 Requires compaction with a steel roilier.
. 004 A.C. to match the greater of existing depth or 4",
. 005 All cuts sealed for final inspection.
. 006 Temporary patch may be used at the end of the day.
007 Signing and Zone protection to comply with MUTeD
. 008 Cut concrete only on score lines or cold joints.
. 009 Sidewalks and driveways min. 3.000psi.
. 010 Curbing min 3.500psi I No patchwork less than 3".
. 0]1 Meet min. requirements on curb cuts, Spfd. code.
. 012 Restore planted areas, Spld. code 206.3.05
. 013 Spec. 10 B(l,(8 I Jack I No A.C. cuts.
. 014 Mechanical compacting required.
. 015 No. patchwork allowed.
. 016 lateral cuts to have control density fill,
. 017 Cuts to be polymerized crack. sealed for final inspection.
oJ 018 Mininum 2" crushed rock %oK minus.
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Comments:
019
020
021
022
023
024
025
026
027
028
029
030
031
032
Minumum 4' clearance at any point, swing-away.
Concrete minimum 4" depth. 3,OOOpsi.
Trench to be 'T' cut.
Needs State I County permit.
No above ground enclosings in sidewalk or handicap ramps.
Diamond cut A.C.lConcrete value boxes to grade.
Fresh Oil signs I Graded.
Comply with Americans with Disabilities Act.
Concrete slabs, 72hrs. curing time, 4500psi.
Concrete slabs require joint seal material.
Driveway requires dowels every 1 a".
Submit traffic control plan prior to excavation.
Notify Traffic Division before excavation.
Core drill main line, Insert tee, 2% min. grade.
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YOU ARE REQUIRED TO CAll
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
o 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 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 WORK IS IN PLACE BUT PRIOR TO POURING CONCRETE.
~T^!'~ER' STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CAll CITY MAINTENANCE AT
~761..
I,. . .
SIGNATURE:
AMOUNT RECEIVED:
RECEIPT NO:
b~~
IF) c19 () /
DATE PAID:
RECEIVED BY:
/?~tf/t1~
I3Y,
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 Drawlngshand the laws of the State of Ore.9on pertaining to the work
described herein. I further certify that only conlractors and employees w 0 are in compHance with ORS 701.055 wiil be used on this
project. ',' ,
The City may inspect the' work site described in this Rermit 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."
e that all required inspections are requested at the proper time, that project address is readable from the street,
f plans will remain on the site at all times during construction.
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Signature
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VALIDATION:
I3}-1'RAFFIC REVIEWED BY: AI/A-
~GINEERIN~ REVIEWED BY: -rtof /vi. ;
o MAINTENANCE:
o PERMIT ISSUED BY:
tJOf?o~
Date
DATE:
DATE:
c
P- -U..<P-S
DATE:
DATE:
FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (CoMPLET,EoI,IN PERMIT.ORA WER.
INSPECTION: DATE: '
. INSPECTION:
.~ORK IN PROGRESS
,AT TIME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
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",;.:
DATE:
DATE:
DATE:
DATE:
DATE:
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Job. No.
q5n~
. SYSTEM DEVELOPMENT CHARGE
WORKSHEET
NAME, G.~ffi~,~ill ~~(JNE'
ADDRESS:~/n Mil ~l)(,t,. to STATE:fl)ZIP:
LOCATION OF PROPOSED BUILDI~ SITE:
Street Address: ~ G() n.s.GY\ , '
Plat Name: ~l W\ ollo.1lJ .. Tax Lol Number: I 'J() 33toll mqQp
, oA PU
1. PEVELPPMErh TYPE; (Check appropriate dwelling(s). SDC calculations and dwelling t
ype definitions are on the back.)
A. Binale-Familv Deta~
. NO. OF UNITS
I
I Manufactured home not in a park
X $1,000 per unit = $ \t(X).cO
Single Family home
B. Binale-Familv Attached
NO. OF UNITS
X $924 per unit' = $
C. Multi-Familv Aoartment
NO. OF UNITS
X $692 per unit = $
D. Manufacturer! Home PArk
NO. OF UNITS
WILLAMALANE SDC
X $699 per'unit = $
$ \crD.cD
2. SDC CREDIT (if applicable) SDC-payer must furnish proof of 1'7<
Willamalane Credit approval. See SDC Credit Worksheet. $ K./
3. TOTAL WILLAMALANE NET SDC ASSESSED
(if SDC reduced for Credit)
~J\~~
Development SelVic~~epartment
City of Springfield
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Date
$ Inco .au
1 1 ~ 1 a~