HomeMy WebLinkAboutPermit Sidewalk 2008-4-2
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DRIVEWAY/SIDEWALK PERMIT APPLICATION
225 FIFTH STREET
" SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION .
OFFICE TELEPHONE (503) 726-3753
APPLICATION DATE
Wi:~
PERMIT NUMBER
DATE ISSUED
SITE INFORMATION
LOCATION OF W~K I /? ~ I
APPLICANT 06 [ h Ut"l
ADDRESS / &; / 0 '-IJ I .
CITY r:AJr I t./tV( STATE
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ZIP CJ, t({j 7_ TAALOT
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SUBDIVISION
OWNER E:::- /if t' tl't' A \ . :rJVtJ2ru~ PHONE
ADDRESS {1 (J, f3f1lf.. _; 7 D '3 STATE /)R ZIP
CITY (f $ I(
REQUESTED PERMITS
l& SIDEWALK $ 8500 =$
AMOUNT OF SIDEWALK IN EXCESS OF 90FT @$O 08 SF =$
o SIDEWALK REPAIR $1500 =$
~ CURB CUT/DRIVEWAY NUMBER OF DRIVEWAYS X $ 85 00 1 st Cut =$
o MULTIPLE PERMIT DISCOUNT EA (MAX 2) $3000 2nd Cut =$J
(MULTI PERMIT DISCOUNT GOOD FOR ONE SITE AND ONE SITE INSPECTION .!lliLY =$
APPLIES TO 2nd AND 3rd PERMITS ONLY NOT SIDEWALK REPAI~
o 5% Technology Fee $ TOTAL DUE WITH PERMIT $
o PROOF OF INSURANCE $500,000 MINIMUM IF WORK IS DONE BY PROPERTYOWNER
CONTRACTOR INFORMATION
CONTRACTOR (J/ /;<<Vj {~U/(u!//14I l:DYe
ADDRESS ! ~~ 71! W, 71?lJfve GViJ t:/LL
CONTRACTOR REGISTRATION !:J9 q / t & 6 .
PROJECT SUPERVISOR I' 0("'1' E(? /1~1f (""
INSPECTIONS
97t(6LpHONE J'~~~~
EXPIRATlONDATE -"7/fJ/o11
PHONE
AN INSPECTION REQUEST SHOULD BE MADE PRIOR TO POURING CONCRETE, AFTER THE PROPOSED WORK HAS BEEN FO RMED 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 OF INSPECTION REQUESTED, AND WHEN YOU WILL BE READY FOR INS PECTION CONTRACTOR'S OR
OWNER S NAME AND PHONE NUMBER REOUESTS RECEIVED BEFORE 7 00 A M WILL BE MADE THE
SAME DAY, REQUESTS AFTER 700 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
YOU ARE REOUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
I ' 11/ "ONE CALL NUMBER" 1-800-332-2344
I ~ I ' 48 HOURS BEFORE DIGGING
j I /J ,,_
SIGNATURE I' ,r I /(J~ I All c.;)
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AMOUNT RECEIVED
DATE PAID
LL-2 ~DJY
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RECEIPT NO
RECEIVED BY
By slgnalure I slate and agree, that / have carefully examIned the compleled applIcatIon and do he reby certIfy thaI all mfOfmabon herem IS llUe
and cOlrecl and I further certifY that any and all work perfOlmed shall be done In accOldance With Ihe Ordinances of
the City of Spnnglleld, appllcanle City Slandard speclllcatlons and DraWings, and the laws 01 the Sidle of Oregon pertaining to the work described herein I further
certify Ihat only contractors and employees who are In compliance With ORS 701 055 Will be used
on thiS project
The City may Inspect the work site descnbed In thiS permit al any lime dunng a one year penod to 1I00000g lhe receipt by the City 01 nollce of com~etlon 01 the
described wOlk and specrfy, at the City'S sole discretion, any addItional resloratlon work reqUired to return the SIIe to a standard accep.table to lhe CI The
permlnae Will be notified In wrlllng of any work reqUlfed and Will have Ihllly days (3D) from the date of Ihe notice to complete the work WOIk nOI comp eled at the end
of the Ihlrty days Will be performed by ttie CIty and the costs Will be billed to ttie permittee .
str"':t~u:::::art~~r~~oe~u~~t~r~~~r~lr~e~~~~t\~ss:ree~?~w~~~~ g~:~n~P~g);'~~~~nthat pro) eel address IS readable from the
Signature
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225 Fmh Street
Springfield, Oregon 97477
541-726-3759 Phone
Job/Journal Number
COM2007-00814
COM2007-00814
COM2007-00814
Payments:
Type of Payment
CredltCard
cRecemtl
RECEIPT #:
DescriptIOn
SIdewalk PermIt
Curbcut PermIt
PW DIsc - 2nd PermIt
PaId By
ROGER D OBERG
City of Springfield Official Receipt
Development Services Department
Public Works Department
1200800000000000300
Date: 04/02/2008
Item Total:
Check Number AuthorIzatIOn
Received By Batch Number Number How ReceIved
ew 090212 In Person
Payment Total:
Page I of I
11:23:28AM
Amount Due
8500
8500
(4500)
$125.00
Amount PaId
$125 00
$125.00
4/2/2008