HomeMy WebLinkAboutPermit Encroachment 2000-6-12
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Gig of Opringfie/d ! .'-~~.
ENCROACHMENT PERMIT APPLICATION
225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726-3753
APPLICATION DATE:. \1111"-"
~I
ENCROACHMENT PERMIT
NUMBER:
DATE ISSUED: G- 12._00
I~""~
I .
LOCATION OF WORK
APPLlCANT!\""A"..AA. ~""', Sr'^'~,;l<..loI MA-c. (~I'f'HONE y::! .:22g7
SITE ADDRESS:,M\~~ ""tlk 0+ bOd.. r\1I.l1 \ iii. S:.+ TAX MAP:
CITY:~^\^M.C H t.lJ
1 I
SUBDIVISION:
OWNER: c';;'lOv: '" \//IN\ ++0\4-\-.........
ADDRESS:? ~ Y ') DO'i\",~a..2 s.t- CITY: eU1..o...N
STATE:oL
ZIP: q ') 4 77
TAX LOT:
PHONE:
STATE: OP
ZIP: "n I./O~
CONTRACTOR:
ADDRESS:
PHONE:
CONTRACTOR REGISTRATION NO:
PROJECT SUPERVISOR:
EXPIRATION DATE:
PHONE:
REQUESTED PERMITS:
INSPECTIONS REQUIRED: APPLICATION FEE I DEPOSIT
ACCOUNT NO:
o ENCROACHMENT PERMIT NO: ................................ (;71
'10V.UU I
VAL.IO FOR SIXTY leal DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
n
o CONSTRUCTION. STORAGE, STAGING
n
*
o OUST CONTROL (TYPE OF CONTROll
o OTHER
n
o ASPHALT DEPOSIT. ........."....... .....'.. ,.,,,,..,,,.. ".,...., ".", ,. ,., '" ,., ,., ,.. ,., ,.". ". ,.,.........,... ... ..... $
o rVPF OF !':Fr.lJRITV OFPO!':IT For:
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH I CHECK $
o SANITARY SEWER CONNECTION: ...... 0 MAIN LINE (EASEMENT-RIWI 0 TO STUB 0 OTHER
o STORM SEWER CONNECTION: 0 CATCH BASIN I BUBBLER 0 STUB 0 MAINLINE
o PROOF OF INSIJRANCE: $500,000 MINIMUM 0 ATTACHED 0 ADDITIONAL REQUIRED AMOUNT
TOTAL DUE WITH PERMIT $
(> 0 . 0>0
DESCRIPTION OF PROJECT:
PERIOD OF USE OR TIME OF CONSTRUCTION:
o PLANS (TWO SETSI ATTACHED
AREA: LENGTH: WIDTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKPILL MATERIAL TO Be UTILIZED:
FROM DATE:,l..\'j \0, 2.COO
TO DATE: />.u '\ '''.' 000
DEPTH:
TIME: 'l...... . ~ da/ly
TIME:
HEIGHT:
BORE:
BACKFILL MATERIAL:
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:
Advance signing and work zone protection to be in compliance with the Manual on Uniform Trallic Control Devices (MUTCD
DESCRIPTION:,Av+<:. Utw...lMo.l~,,^ I...D.A ,.r"^^,,,^h.::'~""'."/ ..... ""'I~\ ~ ~ l\/"IVr-\" IA'
..~ (~~' \~\. P<v-H...-\- .......,\\ tc""""d =~ol~ ..c....v --t'\..o_ ~clo ,~,L.ILlA 'Mo.\,
-I;- I.. ,oj., lo~ 0'" <1".tI 1Ai'-.m'l.t\,. -\-r,-,.n,,,,,,,~. 'Sc.d...~W ,..\11 ';.yol-t........,4 &;'
~(MA '^'n.~l. - Wo d..Ul. ~~"-+l~ ~.~-I-. -;-Ino r-lo\' ( "". til~.J..,.~ -f\.Q\M
...\-"\... (I'''')' d ...:-h "'4'...... -M....'ol- -t'i..... 3 .1l'~J^L-:1 ~ "',:,r"""'b -t\. LA,....IJ ~
\..<. c., -\-V, d..,':l4 -\-cv -n... A "^ .... .. I 1M ".4. -t\-.o. \h It) \ ad .
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THe' CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
REVISIONS 3/29/99
FORM'116