HomeMy WebLinkAboutPermit Encroachment 1999-6-29
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ENCROACHMENT PERMIT APPLICATION
225 FIFTH STREET SPRINorlBLD
SPRINGFIELD, OREGON 97477 ~
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3751 I ~ I
APPLICATION DATE: & / 21 ~~
ENCROA~HMENT PERMIT aa~qD~9
NUMBER. . -l- =r, . '1 t:Ir':I
DATE ISSUED: ~/?q/qr:r - ,
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LOCATION OF WORK
APPLICANT ~ 'ft\>'~
SITE ADDRESS: ~(Pv1 ~wt't- (},
CITY: ~ri# STATE:Dc<-
SUBDIVISION: 1Ld.-..-- ~>
OWNER: MM~(/\o- .M-~
ADDRESS: '3(, ljO ~ ~
CONTRACTOR: [1.{tJLllk /J.-'1:\P4-
PHON E 1l{(p- 2B ~1
TAX MAP:
ZIP:
TAX LOT: Y
CITY:
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PHONE:
STATE: (Jr<-
ZIP: q7t{2't-
PHONE:r'((.-ll {f
ADDRESS:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
~q1q 3
EXPIRATION DATE:
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PHONE:
"REQUESTED PERMITS: 'NSPECTIONS REOUIREO, APPLICATION FEE I DEPOSIT
iii ENCROACHMENT PERMIT NO: .........(l':'t.o.~W.. rv'I $80.00 I
ACCOUNT NO:
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VALID FDA SIXTY [601 DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
[1
o DUST CONTROL ITYPE OF CONTROLI
o CONSTRUCTION. STORAGE. STAGING
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,
,
o OTHER
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o ASPHALT DEPOSIT ................................................................................... ....................... $
o TVPF nF !':Fr.IIRITV DF~ Far:
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH / CHECK $
QV$ANITARY SEWER CONNECTION: ...... ~N LINE !EASEMENT-R/WI 0 TO STUB 0 OTHER
o STORM SEWER CONNECTION: 0 CATCH BASIN / BUBBLER 0 STUB 0 MAINLINE
o PROOF (I" II\I~IIRANCE' $500,000 MINIMUM 0 ATTACHED 0 ADDITIONAL REOUIRED AMOUNT
TOTAL DUE WITH PERMIT $
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DESCRIPTION OF PROJECT:
"'
PERIOD OF USE OR TI ~E OF CONSTRUCTION:
o PLANS (TWO SET II ATTACHED'
AREA: LENGTH: J. WIDTH:
DEPTH:
TIME:
TIME:
HEIGHT:
FROM DATE:
TO DATE:
TYPE OF WORK:
OTHER:
C~~:
t:,j
BORE:
EXISTING SURFACE f'v1f1TERIAL:
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BACKFILL MATERIAL TO BE UTILIZED:
I:
BACKFILL MATERIAL:
SURFACE REPLACEME;n MATERIALS TO BE UTILIZED:
"
A
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
Advance siQning and work zone protection to be in compliance with the Manual on Uniform Traffic Control Devices (MUTeD
DESCRIPTION:
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WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD.
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REVISIONS 3/29/99
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PLAN REVIEW COMMENTS I *IAL INSTRUCTIONS: . :'
RESTORATION WORK SHALL BE IN C~FORMANCE WITH EXISTING CITY CODES A IN COMPLlANCI!'i,OJITH CURRENT
STANDARD SPECIFICATIONS, EXCEPT AS NOTED BELOW.' ~I'h
o 019 Minumurn 4' ~Iearance at any po, t, swing-away.
D 001 Backfill with~. minus rock. 0 020 Concrete minimum 4M depth. 3,ObOpsi.
o 002 Compact every 18" loose depth.. 0 021 Trench to be "r- cut. :,'
O 003 Requires compaction with a steel roilier. 0 '
022 Needs State I County permit. j.;:'
o 004 A.C. to match the greater of existing depth or 4", 0 023 No above ground enclosings in slHewalk or handicap ramps.
O 005 All cuts sealed for final inspection. 0 '1,
024 Diamond cut A.C.lConcrate value, boxes to grade.
D 006 Temporary patch may be used at the end of the day. 0
025 Fresh Oil signs I Graded. _
Do 007 Signing and Zone protection to comply with MUTeD 0 026 Comply with Americans with DiS~biljties Act.
008 Cut concrete only on score lines or cold joints. 0 027 Concrete slabs, 72hrs. curing tini~, 4500psi.
8 009 Sidewalkl end drivewaYI min. 3.000Pli. 0
029 Concrete Ilabl requlr. Joint 1..1 ~.tarlll.
010 Curbing mln 3,eOOpsll No p8tchwork less than 3'. CJ 029 Driveway requires dowels every is".
D 011 Maat mln, re~ulramentl on curb CUll, S~fd, code, D 030 Submit traffic control plan prior to excavation.
o 012 Restore planted areas. Spfd. code 206.3.05 0 031 Notify Traffic Division before,excavation.
o 013 Spec, to Bore I Jack I No A.C. cuts.. 0 032 Core drlllmain line. inl8rt tee. 2%.min. grade.
DO'4 MechanIcal compacting requIred.
DOle No pltchwork allowed. D 033 MUlt comply with the provillonl of ORB 757,li41 to
757.571. .
o 016 Lateral cuts to have control density fill. Gl 343 6" Circular holeIH20-Vac.
DO 017 Cuts to be polymerized crack seated fOf final inspection. 0
018 Mininum 2" crushed rock *" minus.
Comments:
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 (RECORDERI 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.
~M''''-~EWER, STORM SEWER. EN.CROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
r 726-3~ ') 1l7~ '/-0-') t!\ IA~I"l '.. ,
I ___L_ ..lll_II__
SIGNATURE:
QJ2-
AMOUNT RECEIVED: ~
RECEIPT NO: ~ () -< C/ (as ~
DATE PAID:
&170 I q 0;
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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 Drawlngshand the laws of the State of Ore~on pertaining to the work
des.cribed herein. I further certify that only contractors and employees w 0 are in compliance with ORS 701.055 will be used on this
prolect.
The City may insp.ect 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 (301 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 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 Th~ "-M<-~
Date
L,. -.:L.'t -'1"1
VALIDATION:
o TRAFFIC REVIEWED BY:
o
o
o
DATE:
ENGINEERING REVIEWED BY:
DATE:
MAINTENANCE:
DATE:
PERMIT ISSUED BY:
- kaJr. IVI ff ~~
DATE:
&!?C7 /9S
FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETEDIIN PERMIT DRA WER.
INSPECTION: DATE:
INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DATE:
DATE:
DATE:
DATE: