HomeMy WebLinkAboutPermit Sidewalk 1999-4-6
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Cily of upringfield
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DRIVEWAY/SIDEWALK PERMIT APPLICATION
225 FIFTH STREET BP~AJNOP1m..
SPRINGFIELD, OREGON 97477 ~
ENGINEERING DIVISION .&!.
OFFICE TELEPHONE (503) 726,3;'Y.. ~
APPLICATION DATE: 1fa/9 '1
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PERMIT NUMBER: '
DATE ISSUED:
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'IF! 0450
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SITE INFORMATION:
LOCATION OF WORK: S/w elo i='A"h/';;w .. 1'~Sc:oTT
APPLICANT C \ '\<..{ Or;=. SPi2.<,..GtFlal\ PHONE
-o/I/II.:TN F/20t..JT of
ADDRESS: r,; ,-:0, I='A,IZ. V I <= oN DI2,nJt::
snve
71.~~3(PSt...
TAX MAP: 110"3 274'Z.
CITY: 5PIU..."'F/~STATE:
6"
ZIP: 97'-/77 TAX LOT: 02 '101
SUBDIVISION:
OWNER:
J)UAIVe ~^,/~l.J"'{
PHONE:
ADDRESS: 3&,'UJ'C, CAMP CRK. g() CITY: SP12.1 ....(.,.\= 1E1..^
STATE:
C>12.
ZIP: 9"74,'n
REQUESTED PERMITS:
DRIVEWAY ICURB.CUT/SIDEWALK: ...............,............................................,.....",................ $ 60.00
AMMOUNT OF SIDEWALK IN EXCESS OF 90FT. @$0.06 SF. $
o SIDEWALK REPAIR: .....................................................................$ 10.00..,....,..
o ADDITIONAL DRIVEWAY: ....................................................,..$ 30.00.........
o PROOF OF INSURANCE' $500.000 MINIMUM IF WORK IS DONE BY PROPERTY OWNER
TOTAL DUE WITH PERMIT $
CONTRACTOR INFORMATION:
CONTRACTOR: DAvID
ADDRESS: -p 0 &'Y:
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Z<.{.(p
:r~i':1L ~rauc.710rJ INt
VEtvE"TA oR q 7%7 - 07.-'-f1^ PHONE:~O?~S-7'iOI
"7 Z 3'1 '3 EXPIRATION DATE: o31z..,/OI
r"" '3 L E7I... PHONE: ~ I) 7 it( - 8 'U.q
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CONTRACTDR REGISTRATION NO:
PROJECT SUPERVISOR: J:>Avl f)
INSPECTIONS:
AN INSPECTION REQUEST SHOULD BE MADE PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FORMED
AND MADE READY TO POUR.
CURB CUT AND SIDEWALK INSPECTIONS CALL 726,3769 (RECORDER) STATE YOUR DESIGINATED CITY JOB NUMBER/PERMIT
NUMBER, JOB ADDRESS. TYPE QF INSPECTION REQUESTED, AND WHEN YOU WILL BE READY FOR INSPECTION. CONTRACTOR'~
OR OWNER'S NAME AND PHONE NUMBER. REOUESTS RECEIVED BEFDRE 7:00 A.M. WILL BE MADE THE SAME DAY, REQUESTS
AFTER 7:00 A.M. WILL BE MADE THE NEXT WORKING DAY. INSPECTlDNS ARE TO BE CALLED IN AFTER EXCAVATIONS ARE
MADE AND FORM WORK IS IN PLACE BUT PRIOR TO POURING CONCRETE.
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" '-800-332-2344
48 HOURS BEFORE DIGGING
SIGNATURE:
AMOUNT RECEIVED:
RECEIPT NO:
DATE PAID:
RECEIVED BY:
By signature, I state and agree, that I have carefully examined the completed application and do hereby cenify 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.Qon pertaining to the work
described herein. I funher cenify that only contractors and employees w 0 are in compliance with ORS 701,055 will be usad on this
project.
The City may inspect the work site described in this Hermit 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, ne permittee will be notified in writing of any work required and will have thirty
d~ys (30) from the date of jhe notice to complete the work. Work not completed at the an~ of the thiny days will be performed by thl
City and the cost. will be b lied 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
Date