HomeMy WebLinkAboutPermit Encroachment 1999-2-9
'i
226 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726.3763
~
ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: W tJ /'??"
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE '
APPLICATION DATE:
"
DATE ISSUED:
. ,LOCATION OF WORK
APPLICANT ~ L..':b1/(/J' t..!ll.~ t?nw.s'1.-rAr. PHONE
SITE ADDRESS: 7~/) MIH#
CITY: STATE:
SUBDIVISION:
OWNER: 4~.a~ /,(t(I/bJ.JVr.E ~
T' .
ADDRESS: CITY:
CONTRACTOR: ~flJO III1NN &oM, '~DDRESS:
CONTRACTOR REGISTRATION NO: n 7?';L,#!?-;:
7'
PROJECT SUPERVISOR:
ZIP:
.TAX MAP:
TAX LOT:
no>:; ~4t.
-5~o
,PHONE:
,STATE:
I/t) . 1So~ 2..Q1G--, J .AF-..M/~
EXPIRATION,DATE: -::S~-f';P
7#- Qit:1Cl
ZIP:
PHONE: :1~~9_
PHONE:
7~r
REQUESTED PERMITS'
o ENCROACHMENT PERMIT NO: ...............................,.,
YALI) FOR '!XTY 1801 DAYS fROM DATI 0' ISSUANCE
, Q CUT STREET Q BORE Q OTHER n
Q OUST CONTROL (TYPE OF CONTROU
Q CONSTRUCTION. STORAGE, STAGING n
Q OTHER n
o ASPHALT DEPOSiT.....................,....................................,..........................................,.....
TYPE OF ~F~IIRITY DEPOSIT
o BLANKET SURETY BONO Q SURIITY BOND Q CASH I CHECK
INSPECTJOHS AfCUlRlDI Al"PUCAT1OH FU I DUOSIT'
ACCOUNT NO:
o .80.0~
O.
O.
O.
O.
o CURB CUT PERMIT NO:.................... FT. 0 O.10.00H.16/FT.
IN~p'~nN' CUR8 I APPROACH AFT!R FORMS ARI WCTIO BUT rRJOR TO POURlNQ CONCAn!.
. VALl) FOR 110 DAYI fROM DATI W ISSUANCE.
-/ Q SECON'O DRIVEWAY (SEE SEPARATE APPLICATlONI
1!:1 SIDEWALK PERMIT NO:.................... FT. ~ n Q~"-O'OO"'..16/FT. /0.7.r
VAlID 'OR 1.0 DAVS FROM DATI 0' ISIUANCI.
Q NEW Q REMOVE I REPAIR Q PAVE Pl.ANT STRIP
Q'SETBACK Q CURBSIDE Q LENGTH
IN'l:I>F't"TlnloJ. ltIOe:WAUC I DRIVEWAY FOR AU CONCRm PAVING Ym'HlN THe: STREET NClHT Of! WAY, TO BE "
MAD! MTEA AU (XCAYA1lNQ as COMPUTE. AND fORM WORK AHD SUB-BASI MATtRIAI.I8IN f'LACL
o SANITARY SewER CONNECTION PERMIT: .....;.......... n a $6.0'0 I '
VALl) FOR SIXTY 11101 DAYS FROM DAT! D' ISSUANCe:
Q TO STUB Q MAIN UNE IEASEMENT-R/WJ Q OTHER
o STORM SEWER CONNECTION PERMIT: .................... n a $6.00 I
VALl) 'OR IIXTY UIOI DA.... fROM DATI OIIIISUAHCI
Q CATCH BASIN I BUBBLER Q STUB Q MAINUNE ,
fBO.QF nF ''''~'IRANCF. .600,000 MINIMUM h\ ,7-
, Q ATTACHED Q REQUIRED AMOUNT TOTAL DUE:-. / u ~
TOTAL DUE WITH PERMIT. ,(I) . 7~
O.
DESCRIPTION OF PROJECT:
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 UTILIZED:
SURFACE REPLACEM'eNT 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:
Advanc. IlgnIng .nd work, zone .pro'lctlon to b. In compllanc. WIU' tn. Manuel ~ Uniform TraU1c Control D.vlcu (MUTeD),
FROM DATE:
TO DATE:
.a-/?/f'f'
WIDTH:
DEPTH:
TIME:
, TIME:
HEIGHT:
BORE:
, BACKFILL MATERIAL:
DESCRIPTION:
.
WORK SHALL COMPLY WITH CHAPTER X ARTICLE II OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS 8/24181 FORM , III
.
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PLAN REVIEW COMMENTS I SPECIAL INSTRUCTIONS:
RESTORATION WORK SHALL BI! IN CO.AN~f WITH EXISTING CITY CODES A.a c:bMPUANCE WITH CURR~T
STANDARD SPECIFICATIONS, EXCEPT OIl:U DC:l.OW. '''W
,- 001 IlIckfIU WIth.. mlnUl rock. - 019, Mlnumum.' cl..ronc..t .ny point. .wlng..w.y,
:. .
. 002 Comp.ctevery 18"100" d.Pth. . 020 Coner.t. minimum." depth. 3,000p.1.
:. 003 Rlqulrll comp.otfon with. 'till rolll.r. . 021 Trench to bl rr- cut.
,. 004 A.C. to milch the gro.tor 01 exllllng depth or.". 022 N..d. Stet. I County p.rmlt.
: _ 005 AU out. .ur.d for 'In.llnspeotto". 8 023 No .boVl ground Inclollnglln Ildewalk or handicap rampl.
. 008. Temporary pitch m.y bl ulld It the end 01 the day. 024 Diamond cut A.C./Concr.tl value box" to grade.
. 007 Signing .nd Zon~ protection to oomply with MUTCD 025 Fro.h 011 .Ign. I eroded.
. OOB Cut ccncrote only on .coro IIn.. 0, cold JOint.. 02e Comply with Amorlcen. with DI.ebllltlu Act,
. 008 81d.welkt .nd driV.wey, mill, 3,OOOp.~ . 027 Concr.te .I.b" 72hro. curing time. .500p.I,
. 010 CIIrl>lng mln 3.800poll No pllchwork I... then 3'. _ 028 Concrotllleb".qulro 101nll..1 m.terl.I,
_ OIl Me.t min. ..qulrom.ntaon curl> cut., Spld. cod.. 029 Drlveway ..quire. dow.l. .v.ry 18".
_ 012 R.llo.. pl.nt.d,or.... Spfd. code 208.3.05 3 030 Submit trofflc control pl.n prlor to excevetion,
_ 013 Spec. to 80'" J.ck I No A.C. cut.. 031 Notlly Tromc Dlvl.lon beforo exc.v.tlpn,
. 014 . Mechanical complctlng required. . 032 Core drill mlln IInl, Inllrt tot. 2% min. grode.
. 018 No p.tchw~rk ellow.d. _ 933 Mu.t comply with the provl.lon. of ORS 757,541 to 757,571,
OIB Lete..1 cute to h.v. control den.1ty 1111. 343 B' ClrC\llor hol.1H20.v.c.
L 017 Cute tob. polym.rlzed crock ...I.d for IIn.lln.pectlon. 0
c.. .018 Mlnlnum 2- crushed rock J- mlnUI.
, , -1
"
Comments:
.
t,
YOU ARE REQUIRED TO CAll
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSP~CTIONS:
. la/CURB CUT AND SIDEWALK INSPEcnONS CAll 728-3769 (RECORDER) STATE YOUR DESIGINATED CITY JOB
NUMBERIPERMIT NUMBER, JOB ADDRESS. TYPE OF INSPECTION REQUESTED, AND WHEN YOU Will BE READY FOR
INSPECTION, CONTRACTDR'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 WOFjK 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:
rZ/tlh/ .
RECEIV 0 BY: ~~A C~
A/IY f /
. Ill}. C y~ .
By slgneture, I etate and agree~ that I have carefully examined the mplated eppllcatlon and do hereby cartify that ell Information
herein Is We and correct, and further certify that any and all wor performed shall 'be done In accordance w'th the Ordinances of the
City of Springfield applicable Ity Standard specifications and DraWings and the lews of the State of Oregon pertaining to the work
described herein. (further certify that only contractors and employees who are In compliance with ORS 7CYI.055 will be used on this
project. I
The City may Inspect the work site described In this p'ermlt at 'eny time during e one yeer period following the receipt by the City of
notice of, completion of the described work and apeclfy, at thoi Clty'e aole descresslon. any addltlonel restoration work required to
, return tha alte to a ,tandard acceptable to the City. The permlttea will be notified In writing of any work required and will have thirty
" deye (301 from the date Of tha notice to COmplete the work. Work not completed at the enCl of the thirty daye' 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 requllsted at the proper time. thet project address Is readeble 'rom the street,
and the approved set of plans will remain on the site at ell t,mes during construction,
Slg~ature a o'~' ~. Date '~-c::r -qq
AMOUNT RECEIVED:
RECEIPT NO:
/6 < 7..5
io
DATE PAID:
I
, I
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:
:, INSPECTION:
WORK IN PROGRESS
AT TIME OF COMPLETION:
ELEVENTH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DAT~:
DATE:
DATE:
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