HomeMy WebLinkAboutPermit Encroachment 1999-2-1
2.26 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (603) 726.3763
~
.
7~1\e.77.t?A/ }Jo, 03274'2...
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: ~<..J(:5 I' Cf~ 136t
FE f3 , I , '79'3
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE '
APPLIPA TION DATE:
'.
DATE ISSUED:
. LOCA TJON OF WORK
APPUCANT ;..M"OL'N' A6_.r<'
SITE ADDRESS: 99-;- k'iAfrUL~
CITY: ~J:It.,I~~ STATE: t?1'L.
SUBDIVISION: J.I-~YO.E'" f.r.A"'Q/E~' g"o
OWNER: #/H'Q)iN IE:N-r~/~~<::
ADDRESS: Z2S~ P,NYON
C~NTRACTOR: 1hwPv. &N'r.
CONTRACTOR REGISTRATION NO:
Pf\OJECT SUPERVISOR: /1/l A--rr /VI/?"-<.€-
,PHONE
7'7'~- t;.?~t;.
,TAX MAP:
TAX LOT:
1'3 O^- DiD:2-1
~ 0570<>
ZIP: 97'/n
A.o41TJOllIII
CITY: ~P",""";'...(L
ADDRESS:
,PHONE:
STATE: O^.
7'/Y- (;~(;~
ZIP: 97o/'7i
PHONE:
EXPIRATION,DATE: '
REQUESTED PERMITS:
PHONE: 7$1'/I'-~??~
a ENCROACHMENT PERMIT NO: ............................... n
YALI) FOR SIXTY fOOl DAYS MOM DATI 0' ISSUANCI
o CUT STREET 0 BORE 0 OTHER n
o OUST CONTROL (TYPE OF CONTROU
INSI'lCTJOHa RlQUUW)1 AmJCA110H RlI DUOSIT
ACCOUNT NOI
f
.
o t80.00
0$
~.
o CONSTRUCTION, STORAGE, STAGING
o OTHER
n
n
O.
O.
O.
o ASPHALT DEPOSIT ......................................................................................................~."..
TVP~ n~ SECURITY DEPOSIT
o BLANKET SURETY BONO Q SURIITY BOND Q CASH I CHECK
0$
o t10.00H.161FT.
I
ell CURB CUT PERMIT NO: .............,..~... FT. 0
INn~M1nN. CURB I AmOACH AFT!A FORMS ARlIRICTID BUT PRIOR TU POUIUNO CONCRfTt.
, VOU) FOR 110 DAV' FROM DATI 0' lSSUANC!,
o SECOND DRIVEWAY (SEE SEPARATEAPPUCAnONl
~ SIDEWALK PERMIT NO:.................... FT._II? U::, 0
VALID ~R 110 DAVS MOM DATI 0' ISIUANCL
o NEW 0 REMOVE I REPAIR Q PAVE PLANT STRIP
o 'SETBACK Q CURBSIDE 0 LENGTH
INltPlllt'Tlf"l"'. RIDEWALK I DRIVEWAY FOR AU. CONCRITI PAVING WlTH!N THISTRUT RKIHT 0' WAY, TO BE
. MADE AfTER AU.lXCAVATlNQ IS COMPUTE. AND fORM WORK AND IVIoIAS! MATERIAL IS IN I'LACI.
o SANITARY SEWER CONNECTION PERMIT: ,............... n
VALO FOR SIXTY ISOI DAYS FROM DATI Of ISIUAHCI
Q TO STUB 0 MAIN UNE lEASEMENT.R/W) 0 OTHER
o STORM SEWER CONNECTION PERMIT: ....................n
YAU) POR SIXTY ISO) DAV' MOM DATI OfIIUUANCI
Q CATCH BASiN I BUBBLER Q STUB Q MAINUNE
PROO~ O~ INSllRANC~' $600,000 MINIMUM
:, 0 ATTACHED 0 REQUIRED AMOUNT
121 $10.00H.161FT.
11.50
a $6.do I '
o $6.00 I
DESCRIi>TION OF PROJECT:
'.'-'
TOTAL DUE: .
TOTAL DUE WITH PERMIT .
II, '5"'0
II So
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETS) ATTACHED
AREA: LENGTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTIUZED:
SURFACE REPLACEM'1:NT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTI~IZED:
NAME OF OTHER UTiliTIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
Adv.nc. '9\Ino .nd work zone prot.ctlon to b. In c~.nc. With tn. .....null on Uniform TrlUJo Control c.YlCII (MUTeD),
DESCRIPTION: RG7tICJI/6;HJ/) i2.G'1'~/O L,F, of S//Je-kUA-t."/r A-NP C!..oRt!::'
2&,/L(, cUjU3 FO,e. INSf(7t-LO+-TlOAJ .oF a.;~c,?J/Io(.tE"" PIP/!E=""
f'€;€. .efl1J sA-77I€'/-.(, ' ,
FROM DATE:
, TO DATE:
WIDTH:
DEPTH:
TIME:
, TIME:
HEIGHT:
BORE:
BACKFILL MATERIAL:
WORK SHALL, COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS 1IZ4I85 fORM I 118 ' .
.
r
PLAN REVIEW COMMENTS I SPECIAL INSTRUCTIONS:
~~it~~~~~~lWUNm,BM~.~CiE'('JW. EXISTING CITY CODES AN.MPUANCE WITH CURRENT........:.. 0
- 001 Backfll1 WItIII" mlnua rock. - Ole M1numum 4' clurlncl It Iny point, .wlng.lwIY,
. .
. 002 Complct IVlry 18" 10011 dlpth, . 020 Conerltl mlnlmum 4" dlpth, 3,OOOpII.
. 003 Rlqulrlocomplctlon with IItlll roilier, . 021 Tronch to bl"'" cut.
_ 004 A.C, to motch tho erolter 01 "doting dlpth or 4", _ 022, Nlldl Stotll County plrmlt,
. 008 All cutl 1IIIId 10' nnlll",ploilon, . 023 No IbovI ground Incloalngl In Ildlwllk or hlndlclp ,"mp",
. ooS. Tlmponlry pitch mlY bl ulld It tho Ind of thl diY, _ 024 Dllmond cut A.CJConcrotl v.ru. bO'.1 to gr.d.,
. 007 Signing Ind Zon~ protlctlon to comply with MUTCD _ 026 F"lh 011 Ilgnll Gr.d.d, ,
_ 008 Cut concr.to only on Icor. IInll 0, cold Jolntl, . 02e Comply With Am.rlc.nl with Dlllbllltl.1 Act,
ooe 8ldlwalka Ind drIVlWIYI mill. 3,OOOplL .. 027 Coner"" alaba, 72hr.. curine tim., 4600psl,
010 Clnblng mln 3,8ooplll No potchwor!< Ilia than 3', . 028 Concrotlllabl roqul" lolnlllll mlt.~II,
011 Mo.t min. roqulram.nta on curb cuta, Spld. cod.. _ 02S D~vlway roqulral dOWIII IV.ry IS';
012 R.otora pllnt.d,aro.., Spld, codl 20S.3,08 030 Submltt","o control plln p~or to "cI.ltlon,
013 Spoc. to Boro I J.ck I No A,C. cutl," 0 031 Notlly Trolflo Division blfor...c...tlpn,
014 Mlchanl..1 comp.ctlng ,.qvlrad. . 032 Cor. d~1I main IIn., IN.rt tll, 2% mln, gr.de,
018 No p.tchwork allowld, 933 MUlt comply wIth thl provlllon. of ORB 757,641 to 757,671.
. OtS Laterol cutl to haVI oontrol dl"'lIV nn. . , _ 343 S' Clrculer hol.1H2D-Vac,
017 Cutl to be polym.~Zld crack 1.lr.d lor f1n.llnlplctlon, ....
: ' 018 Mlnlnum 2- cNlhed rock ,. mlnUt.
-
"
Commente:
0,
I
YOU ARE REQUIREO TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS 8EFORE DIGGING
INSPECTIONS:
'Q
CURB CUT AND SIDEWALK INSPECTIONS CALL 726-3769IRECORDER) STATE YOUR DESIGINATED CITY JOB
NUMBERIPERMIT 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 WO~K IS IN PLACE BUT PRIOR TO POURING CONCRETE,
a SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
728-3781,
SIGNATURE:
io
pCl3/! /q"1
6~e 77/Jf:Wfe
AMOUNT RECEIVED:
RECEIPT NO:
'I-//,S-D
DATE PAID:
RECEIVED BY:
By signature, I stata and agreet that I haya carafully examined the completad application end do hereby cartify that all information
hareln is true and correct, and further certify that any and all work peiformed shall be done In accordance With the Ordinances of tha
, City of Springfield, epplicable Ity Standard specifications end Drawlngshand the laws of the State of Orellon pertaining to tha work
dascrlbad herein, I furthar certify lhat only contractors and employaas w 0 ara In compliance with ORS 701 ,055 will ba usad on this
'project. ' ,
The CItY. mey Insllect the work site described In thIs "ermlt at 'any time during e on. yea, parlod foliowlng tha recaipt by tha City of
notice of, completion of the dascrlbed work end apac;Lfy' al th, Clty'a Bola dascraaslon, any edditlonal ,estoration workra~uirad to
, ratum the alte to a standard accaptabla to the City. The parmlttae will b. notlflad In writing of eny work ,aquirad and will hava thirty
" days (30) from the date of the notice to complate the work. Work not completad at the en~ of the thirty daye'will b. parformad by tha
CIl'( end tha costs will be billed to the permittee.
, I furthor agree to ensure that ali required Inspecllons ara ,equdsted et tha propar tlma, that p,oJect address Is raadabla from tha streat,
and tha epp,oved eat of plana will remain on tha site at all tlmas during construction,
Slg~ature ~~~~ Date ...2-/-:f?7
VALIDATION: ~
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
, 0 MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
. FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT ORA WER,
, INSPECTION:
; INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
" DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DAT~:
,DATE:
DATE:
"