HomeMy WebLinkAboutPermit Encroachment 1996-1-18
CIT~ OF SPRINGF( ~D PE.~VIIT APPLICATION
225 FIFTH STREET
SPRINGFIELD, OREGDN 97477
ENGINEERING DIVISION
OFFICE TELEPHDNE (503) 726,3753
BPRINGP'IELD
~
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: q"oo7~
(SIDt::WAV<:- )
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
APPLlCA nON DATE: I /Ish ~
"
DATE ISSUED:
I;; e. ['"
LOCATION OF WORK
APPLICANT r-ielWk
SITE ADDRESS:
fl,Zs-
.,-rc.orrt:a
t:=ArIZ.VIt::'<J
( oWHtZtZ. \
PHONE
'IS'>' --z:'2.. 'Z. s
TAX MAP:
TAX LOT:
" 03 z74'Z.
o z.'300
-
CITY: $P(!iH6t"'I!LO
STATE:
OR.
ZIP: '11'(77
SUBDIVISIDN:
OWNER: ~K nzc1'l"a
ADDRESS: CITY:
(:,Etr AS.".. '\ PHONE:
STATE: ZIP:
CONTRACTOR:
CONTRACTOR REGISTRATION ND:
PRDJECT SUPERVISOR: u,eo'j
ADDRESS:
PHONE:
EXPIRATION DATE: -
..... E:~ ~R.
PHONE:
953- '12SS- _
....I/dr- .......,- -: -}
REQUESTED PERMITS:
INSPECTIONS REQUIRED: APPUCATION FEE I DEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ............................... n
VAllO FOR SIXTY 1601 DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
o DUST CONTROL (TYPE OF CONTROLI
n
0 $20.00 I
0 $
0 $
0 $
0 $
0 $
0 $10,OO+$.15/FT.
o $10.00H.15/FT. 17 !!."
o CONSTRUCTION, STORAGE. STAGING
o OTHER
o ASPHALT DEPOSiT..........."..."..,,,.......
n
n
IYPF OF "'EC.I.U"TV nFPo'::'1
o BLANKET SURETY BONO 0 SURIITY BOND 0 CASH / CHECK '
o CURB CUT PERMIT NO: .................... FT. n
IN!;PF~TtON. CURB I APPROACH AffiR FORMS ARE ERECTED BUT PflIOR TO POURING CONCRETE.
VALID FOR 180 DAYS FROM DATE OF ISSUANCE.
o SECOND DRIVEWA V (SEE SEPARATE APPUCA liON)
~ SIDEWALK PERMIT NO: ..f~!'!~!:1.5:..... FT. 52-,:r. ~ SI(lE:....A~k
VALlO FOR 180 DAYS FROM DATE OF ISSUANCE.
)2!l NEW 0 REMOVE / REPAIR 0 PAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
IN~PFr.TlnN' !';IDEWALK / DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
MADE AFTER ALL EXCAVATING IS COMPLETE. AND FORM WORK AND SUB.BASE MATERIAL IS IN PLACE.
o SANITARY SEWER CONNECTION PERMIT: ................ n
VALlO FOR SIXTY (601 DAYS FROM DATE OF ISSUANC'E
o TO STUB 0 MAIN LINE {EASEMENT,R/WI 0 OTHER
STORM SEWER CONNECTION PERMIT: ....................n
o $5,00 I .
o
VALlO FOR SIXTY 1601 DAYS FROM DATE OF ISSUANCE
o CATCH BASIN 1 BUBBLER 0 STUB 0 MAINLINE
PROOF OF INSLJRANCF' $500.000 MINIMUM
o ATTACHED 0 REQUIRED AMOUNT
o $5.00 I
TOTAL DUE: $
TOTAL DUE WITH PERMIT $
17~
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 MATERIAL:
BACKFILL MATERIAL TD BE UTILIZED:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PRDJECT:
FROM DATE:
TO DATE:
DEPTH:
TIME:
TIME:
HEIGHT:
BORE:
BACKFILL MATERIAL:
WARNING DEVICES TO BE UTILIZED:
Advance signing and work zone protection to be in compliance with the Manual on Uniform Traffic Control Devices (MUTeD),
DESCRIPTION:
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS 8/24/95 FORM , 116
.
PLAN REVIEW COMMENTS I SP:lAL INSTRUCTIONS: ...
RESTORATION WORK SHALL BE IN C ORMANCE WITH EXISTING CITY CODES AilJI!I!IIIN ~MPLlANCE WITH CURR'iiH
STANDARD SPECIFICATIONS. EXCEPT AS NOTED BELOW. ' --
8. 001 Backfill with %" minus rock. _ 019 Minumum 4' clearance at any point. swing-away.
002 Compact every 18" loose depth. _ 020 Concrete minimum 4" depth, 3.000psi.
_ 003 Requires compaction with 8 steel roilier. _ 021 Trench to be "T" cut.
_ 004 A.C. to match the greater of existing depth or 4". 022 Needs State I County permit.
005 All cuts sealed for final inspection. _ 023 No above ground enclosings in sidewalk or handicap ramps.
_ 006 Temporary patch may be used at the end of the day. _ 024 Diamond cut A.C.'!Concrete value boxes to grade.
_ 007 Signing and Zone protection to comply with MUTeD 025 Fresh Oil signs I Graded.
008 Cut concrete only on score lines or cold joints. _ 026 Comply with Americans with Disabilities Act.
009 Sidewalks and driveways min. 3,OOOpsi. _ 027 Concrete slabs, 72hrs. curing time, 4500psi.
_ 010 Curbing min 3.500psi / No'patchwork less than 3'. _ 028 Concrete slabs require joint seal material.
_ 011 Meet min. requirements on curb cuts, Spfd. code. _ 029 Driveway requires dowels every 18".
_ 012 Restore planted areas, Spfd. code 206.3.05 030 Submit traffic control plan prior to excavation.
_ 013 Spec. to Bore / Jack / No A.C. cuts. 031 Notify Traffic Division before excavati~n.
_ 014 Mechanical compacting required. _ 032 Core drill main line. insert tee, 2% min. grade.
_ 015 No patchwork allowed. _ 033 Must comply with the provisions of ORS 757.541 to 757.571.
_ 016 lateral cuts to have control density fill. _ 343 6" Circular hole/H20-Vac.
_ 017 Cuts to be polymerized crack sealed for final inspection.
018 Mininum r crushed rock ".. 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:
~
CURB CUT AND SIDEWALK INSPECTIONS CALL 726-3769 (RECORDER) STATE YOUR DESIGINATED CITY JDB
NUMBER/PERMIT NUMBER, JOB ADDRESS, TYPE OF INSPECTION REQUESTED, AND WHEN YOU WILL BE READY FDR
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 EXCAVATlDNS ARE MADE AND FORM WORK IS IN PLACE BUT PRIOR TD POURING CONCRETE,
o SANITARY SEWER. STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
726,3761,
SIGNATURE:
AMOUNT RECEIVED:
'7~
DATE PAID:
RECEIVED BY:
,le/%
RECEIPT NO:
'" ZO/O-'
1:,.. <AI/;..I-.._
By signature, I state and agree 1 that I have carefully examined the completed application and do hereby certify that all information
herein is true and correct, and 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 Oregon pertaining to the work
des.cribed herein. I further certify that only contractors and employees w 0 are in compliance with ORS 70-1.055 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 (301 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 further 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
~~.~~
Date
1- \\-"'J..
VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
o MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
FOR S/DEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETED/IN PERMIT DRAWER.
INSPECTION: DATE:
INSPECTION: DATE:
WORK IN PROGRESS DATE:
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
J
....
...-t.....,
.
Ci"ty of S~'r'ing;iljld
225 Fif'~~\ Str'0et
Spl~ingficld, OR 9~'4~'~'
(5G3 j 72b-3"('53
Tr';Jns;Jci; lOll (\!.JlIIber'
.Jr.lf)ll;Jr'y 18, 1.3~:b
D2D.LD?
,i" ;39 r'fri
r\8C'P.l ved ~'r'oI11 ~
Cor\\ract/Gw~ ~ FR~NI( TROTTER
Add~~ss= ~25 FAIRVIEW
City: SPRINGFIELD
S't; ~ OF; /....1) ~
-'Hi,illd'ing-
Job ;fl.; 3e0075
~. DE.'scr'lp.t.i.on
Si(i(~~I.oIal1:
"
T ot;jJ.. ~
Anlt r.:eceiv....::.fj=
Cheek ;/\:: '36 '.I.
iI' ~ 8G C:.,t.~~h
,/
/
Th;Jnk '((il,1 ~ 1'1"-0; ~i"
/
/
I
;
;
i
. ._~
~.",:" ~ ao
......., "....
~'1 f '1- I i
..... '.....
J,t .aU
I ...
,". I"
.
F t.'E.\
"
"
.......,
.,;~;
'.'
I,
.):;,
... ,.