HomeMy WebLinkAboutPermit Encroachment 1996-12-17
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-, CITY OF..SPRINGL..:Li:f:~,;,:":,' , . ,';:, p', JMIT APPLICATION
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225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
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ENCROACHMENT PERMIT 'I A.lJv.)'" 4-
NUMBER:
PERMIT NUMBER: '9"'/~?9'
p~C# ~6-<'3-$3
DATE ISSUED:
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
APPLlc:;A TION DATE:
LOCATION OF WORK =z.~ /S#~7"
APPLICANT ~ T~<f'.TL,o/
SITE AODRESS: -::;?~:::> hA-/~ ~ -; ;::??-.
CITY: ~~0 STATE: ~A ZIP:
?7.
PHONE ~~2- 7/:?~
TAX MAP: /?~~'~_~
~ 9?? TAX LOT: ~/;'/'9-
SUBOIVISION:
OWNER: ----/-?,E ~7'7'-L r
ADDRESS: /~..<:. t.../-..:r 6?'"'" "ITY: E~
CONTRACTOR: 7/~~~1/ ADDRESS:
CONTRACTOR REGISTRATION NO: .6~/
PROJECT SUPERVISOR:
STATE:
PHONE:
,~
3y?-3'/<~
. ZIP: ""30::::> 9'<=="~
PHONE:
EXPIRATION DATE: 8--:2/-"'3J.?
PHONE: '9:i!!i'Y -~~
REQUESTED PERMITS:
INSPECTIONS REOUIRED: APf'UCAT10N FEE' OEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ............................... n
VALID FOR SIXTY 1601 OAYS FROM OATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
n
0 $20,00 I
0 $
0 $
0 $
0 $
0 $
0 $10,OO+$.15/FT,
o OUST CONTROL (TYPE OF CONTROL)
o CONSTRUCTION, STORAGE, STAGING
o OTHER
o ASPHALT DEPOSIT.................. ........................
TVPF nF !;Fr.1JRITV nF~
o BLANKET SURETY BOND 0 SURIITY BOND
n
n
o CASH / CHECK
o CURB CUT PERMIT NO: .................... FT, 0
IN~PFcTlnN. CURB I APPROACH AFTER FORMS ARE ERECTED BUT PRIOR TO POURING CONCRETE.
VAllO FOR 180 DAYS FROM OATE OF ISSUANCE.
o SECON'O DRIVEWA Y {SEE SEPARATE APPLlCA TrON)
~
o SIDEWALK PERMIT NO:............,....... FT,
VAllO FOR 180 DAYS FROM DATE OF ISSUANCE.
o NEW 0 REMOVE I REPAIR 0 PAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
ill.S~E"Tln.r-': <:IDEWALK I DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
MADE AFTER ALL EXCAVATING IS COMPLETE. ANO FORM WORK ANO SUB.BASE MATERIAL IS IN PLACE.
~ SANITARY SEWER CONNECTION PERMIT: ................ f'l
VALID FOR SIXTY (601 DAYS FROM OATE OF ISSUANCE
o TO STUB 0 MAIN LINE (EASEMENT-R/WI 0 OTHER
)iJI' STORM SEWER CONNECTION PERMIT: ..................., n
o
o $10,OO+$,15/FT,
~ $5,00 I '
.a:;: -0
VALID FOR SIXTY (601 DAYS FROM DATE OF ISSUANCE
o CATCH BASIN I BUBBLER 0 STUB 0 MAINLINE
ER(1nF nF IN!;IIR~ $500.000 MINIMUM
o ATTACHED 0 REOUIRED AMOUNT
JZI $5,00 I
5:-e>
TOTAL DUE;"$
TOTAL DUE WITH PERMIT $
/p.~
DESCRIPT'ION OF PROJECT: &5......_."., ~M-'~ V- 4~~
1
DEPTH:
7.;t.~,M~~
r; ;,'
TIME:
TIME:
HEIGHT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETSI ATTACHED
AREA: LENGTH: WIDTH:
TYPE OF WORK: ' CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILlZEO:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVlaS TO BE UTILIZED:
FROM DATE:
TO DATE:
BORE:
BACKFILL MATERIAL:
Advance signing and work zone protectio~ to be in compliance with the Manual on Uniform Traffic Control Oevices (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 SPEl' L INSTRUCTIONS: ..
RESTORATION WORK SHALL BE IN CO MANCE WITH EXISTING CITY COOES AN~ doMPLlANCE WITH CURRENT
STANDARD SPECIFICATIONS, EXCEPT A NOTED BELOW.
J 001
. 002
. 003
. 004
005
006
_ 007
_ 008
009
. 010
. 0"
012
013
014
015
. 016
017
.
018
Comments:
Backfill wit~ %. minus rock.
Compact every 18" loose depth.
Requires compaction with a steel roJlJer.
A.C. to match the greater of existing depth or 4".
All cuts sealed for finaUnspection.
Temporary patch may be used at the end of the day.
Signing and Zone ,protection t.o comply with MUTeD
Cut concrete only on score lines or cold joints.
Sidewalks and driveways min. 3.000psi.
Curbing min 3.50Qpsi I No patchwork less than 3'.
Meet min, requirements on curb cuts. Spfd. code.
Restore planted areas, Spfd. code 206.3.05
Spec. to Bore I Jack I No A.C. cuts.,
Mechanical compacting required.
No patchwork allowed.
Lateral cuts to have control density fill.
Cuts to be .polymerized crack sealed for final inspection.
Mininum 2" crushed rock %" minus,
019
020
021
022
023
024
_ 025
..J 026
027
028
029'
030
031
032
Oe3
343
Minumum 4' clearance ot any point, swing-away.
Concrete minimum 4" depth, 3,QOOpsi.
Trench to be "T" cut.
Needs State / County permit.
No above ground enclosings in sidewalk or handicap ramps.
Diamond cut A.C./Concrete value boxes to grade.
Fresh Oil signs / Graded.
Comply with Americans with Disabilities. Act.
Concrete slabs, 72hrs. curing time, 4500~si.
Concrete slabs require joint seal material.
Driveway requires dowels every 18".
Submit tralfic control plan prior to excavation.
Notify Traffic Division before excavatit"n.
Core drill main line, insert tee, 2% min. grade.
Must comply with the provisions of OAS 757.54110 757,571.
6" Circular hole/H20-Vae.
-
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
o CURB CUT AND SIDEWALK INSPECTIONS CALL 726-3769 (RECORDER) 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, REOUESTS 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,
o SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
726-3761,
SIGNATURE:
AMOUNT RECEIVED: /0. p .".
RECEIPT NO: -::? 'I e::-7y
/::?'"'/?, ~
~--_.-.-...:
~~""..~
DATE PAID:
RECEIVED BY:
-
'-...
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 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 Drawmgshand the laws of the State of Oregon pertaining to the work
described herein. I further certify that only contractors and employees w 0 are in compliance with GRS 701.055 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 (30) 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 e~sure that all requiJAd inspections are requested at the proper time, that project address is retld<lble from the street,
and the approved set of plans will reiji)in on the site at all times during construction.. .
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Signature
Date
/2. - /;Z - '1L
VALIDATION:
,
0 TRAFFIC REVIEWED BY: DATE:
0 ENGINEERING REVIEWED BY: DATE:
0 MAINTENANCE: DATE:
0 PERMIT ISSUED BY: DATE:
FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT DRA WER,
INSPECTION: DA TE:
INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
OATE: j
DATE: