HomeMy WebLinkAboutPermit Encroachment 1996-9-25
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CITY OF SPRINGf..~L.p_"" PL~MIT APPLICATION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
SPRINO"'IELO
JiLJ'II
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: 9't; J ?.ff'?
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
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APPLICATION DATE: f - ,;<..::r ~ 9' r<
DATE ISSUED:
LOCATION OF WORK
APPLICANT 5-d"",,:--: .{
SITE ADDRESS: t?Zld (
CITY: i.<::?r,;s:;,r-- ()
SUBDIVISION:
OWNER: Ll2r..-,J /...{1)o'//1/77
ADDRESS: I "S ~,.n ,CITY: STATE:
CONTRACTOR:;tif....,.,.["I..\ e?...('.;,-t..'~Ifl'?f!;:S: -<[1;77.0 6-,....J .'d"..Q.~ PHONE:
CONTRACTOR REGISTRATION NO: 0"3 9;;2 X'-7 EXPIRATION DATE: c;:- ?7
. /; y 9'"7
PROJECT SUPERVISOR: ~ - Z. - PHONE: :2..4..7 -I ~ PL-
.,
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~~-kG;,~ :;-c~ PHONE 7J.'7~/ ~ ~/
~",~_,~_ ~rl1.~dVI'71l:/A TAX MAP: 110~1-4 DC")
STATE: ~,....,p ZIP: 1'74!1'l TAX LOT: .OCJ"l(\q
PHONE:
ZIP:
REQUESTED PERMITS:
INSPECTIONS REQUIRED: APPUCATION FEE' DEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ............................... n
VALID FOR SIXTY 1601 DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
o OUST CONTROL ITYPE OF CaNTRaLl
o
0 $20.00/
0 $
0 $
0 $
0 $ '. .
0 $
0 $10.00 + $.15/FT.
o $10.00+$.15/FT. ~6~
o CONSTRUCTION, STORAGE, STAGING
o OTHER
o ASPHALT DEPOSIT
n
n
TYPF OF ~E.C..U..RLTY nFPn~IT
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH I CHECK
o CURB CUT PERMIT NO: .................... FT. n
IN!;PFCTION. CURB I APPROACH AFTER FORMS ARE ERECTED BUT PRIOR TO POURING CONCRETE.
. ., VALID FOR lao DAYS FROM DATE OF ISSUANCE.
_ /0 SECOND DRIVEWAY (SEE SEPARATE APPlICA nON)
\!1 SIDEWALK PERMIT NO: .................... FT. 0
VALID FOR lao DAYS FROM DATE OF ISSUANCE.
o NEW 0 REMOVE I REPAIR 0 PAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
1~<;~,..I'r'l:t...SIDEWALK J DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
MADE AFTER ALL EXCAVATING IS COMPLETE. AND FORM WORK AND SUB,BASE MATERiAl IS IN PlACE,
.0 SANITARV SEWER CONNECTION PERMIT: ................ n
VALID FOR SIXTY (60) DAYS FROM DATE OF ISSUANCE -
o TO STUB 0 MAIN LINE IEASEMENT-RIWI 0 OTHER
O' STORM SEWER CONNECTION PERMIT: ....................n
VALID FOR SIXTY (60) DAYS FROM DATE OF ISSUANCE
O'CATCH BASIN I BUBBLER 0 STUB 0 MAINliNE
PROOF OF IN"'IIRANCE' $500,000 MINIMUM
o ATTACHEO 0 REQUIRED AMOUNT
o $5,ciq,l,
o $5.00/
TOTAL DUE: $
TOTAL DUE WITH PERMIT $
", ,,;:<?~c:>u
,..9 5- ~-
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETS) ATTACHED
AREA: LENGTH: .WIDTH:
TYPE OF WORK:' - - CUT: ' '
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZED:
SURFACE REPLACEMENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
FROM DATE:
TO DATE:
DEPTH:
TIME:
TIME:
HEIGHT:
,-
BORE:
BACKFILL MATERIAL:
Advance signing and work zone protection to be in compliance with the Manual on Uniform Traffic Control Oevices (MUTeD).
DESCRIPTION:
WORK SHALL COMPLV WITH CHAPTER X ARTICLE 5 OF THE CITV CODE. CONTRACTOR TO COMPLY WITH MUTCD.
REVISIONS 8/24/95 FORM f1 116
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PLAN REVIEW COMMENTS I SP~L INSTRUCTIONS:.
RESTORATION WORK SHALL BE IN C.RMANCE WITH EXISTING CITY CODES AND IN <:DMPLlANCE WITH CURRENT
STANDARD SPECIFICATIONS, EXCEPT AS NOTED BELOW.
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Comments:
001
002
003
004
005
006
007
008
009
010
011
012
013
014
015
016
017
018
Backfill with %. minus rock.
Compact every 18" loose depth,
Requires compaction with a steel roilier.
A.C. t'o'" match the greater of existing depth or 4 ~.
All cuts sealed for finel inspection.
Temporary p~tch may.be-used at the end of the day.
Signing and Zone protection to comply with MUTeD
Cut concrete only on score tines or cold joints.
Sidewelks end driveways min. 3.000psi.
Curbing min 3,500psi 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..
Mechar;'ical cOTpac~ing required,
No patchwork. allowed.
:Late~al cuts to h~'ve control density fill, \ '
I
Cuts to be polymerized crack sealed for final inspection.
Mininum 2" crushed rock *'" minus,
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019
020
021
022
023
024
025
026
027
028
029
030
031
032
033
343
Minumum 4' clearance at any point. swing-away.
Concrete minimum 4" depth, 3.000psi.
Trench to be HT" cut,
Needs State / County permit.
No above ground enclosings in sidewalk or handicap (amps.
Diamond cut A.C./Concrete value boxes to grade.
Fresh Oil signs / Graded.
Comply with Americans with Disabilities Act.
Concrete slabs, 72hrs. curing time, 4500psi.
Concrete slabs require joint seal material,
Driveway requires dowels every 18".
Submit traffic control plan prior to excavation.
Notify Traffic Division before excavati~n.
Core drill main line,_ insert tee, 2% min, grade,
Must comply with the provisions of OAS 757.541 10757.571.
6" Circular hole/H20.Vac.
VOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
~B CUT AND SIDEWALK INSPECTIONS CALL 726-3769 (RECOROER) STATE YOUR OESIGINATEO 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 SE
CALLED IN AFTER EXCAVATIONS ARE MADE AND FORM WORK IS IN PLACE BUT PRIOR TO POURING CONCRETE.
,8- 3A~~;TARY'5E'v'VEn.STORM-SEVvER;'~NCROACnivii:i"I'PcRj\t1fT-AND'uTHER INSPECTiONS 'CALL (;i'rY'MA1NTENANCE AT
726-3761..
SIGNATURE:
AMOUNT RECEIVED: ...0<" p-
RECEIPT NO: 2'3 ztJ1
DATE PAID:
RECEIVED BY:
9-- 25 -'1~
~~ ,e~
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
City of Springfield, applicable City Standard specifications and Drawlngshand 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 ORS 701.055 will be used on this
project. .
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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 end 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 'X ~/.(2 ~-'-
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VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
o MAINTENANCE:
o PERMIT ISSUED BY:
Date y. ?-2::s---9~
DATE:
DATE:
DATE:
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:
DATE:
DATE: