HomeMy WebLinkAboutPermit Encroachment 1996-3-18
CkTY OF SPRINGFf '_0 PE. 'Mil APPLlCA liON
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2~~ ,FIFTH STREET
SPRINGFIELD. OREGON 97477 -
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726.3753
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ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: Cf ca 0 ? 5'S' f-
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PHONE: 7~Y-/708 "'i
/!P 4 ZIP: 9' 7 Y 1t:?" :iil
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s......",4,.0i' PHONE:-: 71,/7-8v9 J '{
EXPIRATION DATE:! 96//;)V
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INSPECTION LINE SEE INSPECTIONS. ON BACK SIDE
APPLICA nON DATE:
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DATE ISSUED:
LOCATION OF WORK ~
APPLICANT :
SITE ADDRESS:
CITY: . .s;.i'd
SUBDIVISION:
OWNER: A'",.,. L. J/"r,;.. cf? S....,/h /r'. TVIoo.5
ADDRESS: (76.8"6:2 ..2l/H ,'er,&r CITY, 5,1.4/
CONTRACTOR:;: /)e..: r .-"1:~:..t... ADDRESS:
CONTRACTOR REGISTRATION NO: CC t3 #6..26 f .2
PROJECT SUPERVISOR:
A'''I.'' L. J>. ~:.
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PHONE
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STATE: 't:?~
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97Y78"
ZIP:
REQUESTED PERMITS:
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INS~"... .,"', ,.. REQUIRED: APPUCAnON FEE J DEPOSIT
ACCOUNT NO:
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o ENCROACHMENT PERMIT NO: .....::...:..:................. n
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VALID FOR SIXTY 1601 DAYS FROM DATE OF ISSUANCE l .' . . f .
o CUT STREET 0 BORE 0 OTHER rj
o DUST CONTROL (TYPE OF CONTROLI
o CONSTRUCTION. STOAJ!.GE. STAGING .. n
o OTHER .; ,. n
o ASPHALT OEPOSIT.............................................. ........,:... ....~......... ................ ....................
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IYfE.!l~ .c;~~IIRITV nEPOSIT , ..' ,
o BLANKET SURETY BOND 0 SURIITY BOND., .0 CASH 1 CHECK
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o CURB CUT PERMIT NO: ;................:.. FT. #300
. . INRP~r.TInN, CURB I APPROACH AFTER FORMS ARE ERECTED BUT PRIOR TO POURINQ CONCRETE.
VALID FOR lBOOAYS FROM DATE OF lSSUANCE:.
..0 SECOND DRIVEWAY (SEE SEPARATE APPUCATIONI
o SIDEWALK PERMIT NO:.................... FT. n
VALID FOR 180 DAYS FROM DATI! OF ISSUANCE.
o NEW 0 REMOVE 1 REPAIR, o PAVE PLANT STRIP"
o SETBACK 0 CURBSIDE 0 LENGTH
IN"~rTlnN' !l:IDEWAlK , DRIVEWAY FOR ALL CONCRETl!: PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
MADE AFTER ALL EXCAVATING IS COMPLETE, AND FORM \YORK AND SUB-BASE MATERIAL IS IN PLACE,
D SANITARY SEWER CONNECTION PERMIT: ................ n
VALlO FOR SIXTY 1801 DAYS FROM DATE OF ISSUANCE
o TO STUB 0 MAIN LINE (EASEMENT .RIWI 0 OTHER
o STORM SEWER .cONNECTION PERMIT:.................... n
, 'VALID FOR SIXTY 1601 DAYS FROM DATE OF ISSUANCE '.
o CATCH BASIN I BUBBLER 0 STUB. 0 MAINLINE
PROOF OF INSlIRANCF' 8500.000 MINIMUM
o A'TTACHED 0 REQUIRED AMOUNT
0 $20.00 I
0 $
0 $
0 $
0 $
0 $
0 $10.00+$.15/FT. 14.50
o $10.00H.15/FT.
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o $5.001
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TOTAL DUE: 8
TOTAL DUE WITH PERMIT 8
14.'50
14.'50
DESCRIPTION OF PROJECT:
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TYPE OF WORK:, CUT:' (' BORE:' ."
OTHER: ; .'
EXISTING SURFACE MATERIAL: BACKFILL MATERIAL:
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BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEMeNT MATERIALS T9 BE UTIL.IZED:
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A .~OINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
.. Advance signing and work zone protection to be in compliance with tne Mllnulli on Uniform Traffic Control Devices (MUTeDI, :, .~
DE:CRIPTION:---8'~...~,/~, e.","r';~\;;' ?:-~~ _../ Co. ;4,., ,.:t.l'r po/' rtp ~"u..~,}.,,:~~
,.... ~el4f"'. -/.0 r~""/,~"'V.-,/~""",'},... ~n~ +" "'~/.1 h._dr ~ ~,/ illl
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WORK SHALL COMPL V WITH CfiAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD. . ~~ !
I' REVISIONS 8/241115 FORM 1.116 .' . i~d
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PERIOD OF USE OR TIME OF CONSTRUCTION, '.,.
. 0 PLANS (TWO SETS) ATTACHED i
AREA: LENGTH:. ..,w'DTH:
. FROM DATE:
TO. DATE: -
DEPTH:.
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TIME:
TIME:
HEIGHT:
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lio'~'PLAN REVIEW COMMENTS I SPVL INSTRUCTIONS:
~'~~\RESTORATION WORK SHALL BE IN CO.RMANCE WITH EXISTING CITY. CODES AA c:tlMPUANCE WITH CURRENT.
,fS.!ANDARD SPECIFICATIONS, EXCEPT As NOTED BELOW. '.. ..., '''.
.~ 001 Back.fill with %- minus rock. ~ 019 Minumum 4' clearance at any point. swing-away.
13: 002 Compact every 18" loose depth. 020 Concrete minImum 4" depth, 3.000psl. .
. \ _ 003 Requires compaction with 8 steel roilier. 021 Trench to be "T" cut.
J)'. 004 A.C. to match the greeter of existing depth or 4". 022 Needs State I County permit. ,I .
:~, . 005 All cuts sealed for final inspection. 023 No above ground encloslngs In sidewalk or handicap ramps.
,til~ . 006 Temporary patch may be used at the end of the day: _ 024 Diamond cut A.C./Concrete value boxes to grade.
:4~, . 007 Signing end Zone protection to comply with MUTeD _ 025 Fresh 011 signs/ Graded.
:t. 008 Cut concrete only on score lines or cold joints. _ 026 Comply with Americans with Dlsablllties Act.
t1t-. 009 Sidewalks and driveways min. 3,OOOpsl. 027 Concrete slabs, 72hrs. curing time. 4500psl.
{:It:. 010 Curbing min 3.500psll No patchwork less than 3'. ~ 028 Concrete slabs require joInt seal material.
"~i. 011 M.., min. requlremllO" on curb cuta. Spfd. cod.. ,- 029 Driveway requlrea dowela every lS-.
',':! 012 Restore planted area8, Spfd..code 206.3.05 030 Submit traffic control plan prior to excavation.
)X~.: 013 Spec. to Bore I Jack I No A.C. cuts. . 031 Notify Traffic Division before excavatipn: -
~l~. 014 Mechanical compa~ing requIred. . 032 Cora drill mal~ line. ~nsert tee. 2% min. grade.
;:t~. 016 No patchwork allowed. 033 Must comply with the provisions of OAS 757.541 to 757.671.
':'zj 016 Lateral cuts to hava control density fill. . 343 6" Circular holaIH20-Vac.
t~t: 017 Cuts to be polymerized crack sealed for final inspectIon.
~lJ __ 018 Minlnum 2" crushed rock %" minus.
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~~1 Comments:
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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:
,: ' Ilil' 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. .
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'~'';l 0 SANITARY SEWER, STORM SEWER. ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
l 726.3761. ' ,
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~ii SIGNATURE:
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.q 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 further certify that any and all work performed shall be done. in accordance With the Ordinances of the
ii, 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 7<Y1.055 will be used on this
~\~:"proJect. ... ,
'i i 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
"I:':; 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
"I . days (30) from the date of the notice to complete the work. Work not completed at the en~ of the thirty days will be performed by the
oJ., City and the costs will be billed to the permittee.
.,r 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 et all times during construction. '
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AMOUNT RECEIVED:
. RECEIPT NO:
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DATE PAID:
RECEIVED BY:
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Date
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r; VALIDATION:
',' 0 TRAFFIC REVIEWED BY:
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.Jf.:O ENGINEERING REVIEWED BY:
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,,0 MAINTENANCE:
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t ~" '.Q PERMIT ISSUED BY:
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I ! f. ..! INSPECTION:. .'.. ',. ". ' . '" DA T~: .
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; 'I. i1NSPECTION: DATE:
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f V::WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DATE:
DATE:
DATE:
DATE:.
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I' f . '.; DEPOSIT RETURNED:
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DATE:
DATE:
DATE:
DATE:
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