HomeMy WebLinkAboutPermit Encroachment 1996-1-18
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" ;,()CITY OF SPRINGF[kp P(JVIIT APPLICATION
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225 FIFTH STREET
SPRINGFIELD, OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726.3753
8PRINOf"lBLD
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ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: '9 ")0 ~ <:) ( n
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE
APPLICATION DATE: f- IP, -9 (0
DATE ISSUED:
"
LOCATION OF WORK
APPLICANT /11~ ~ n, R1 r, It:: I C. PHONE
SITE ADDRESS: 9r:> g fA I TFi? 1/914 T I/\W J4. [, .../ I J 4.J,,0
CITY: 5.oc/_v STATE: 02- ZIP:c:),,d.,'7
SUBDIVISION:
OWNER: 7-i 1.I c. v'- DJ
ADDRESS: "" 40 c:; ~LD0 J.;;'(~trY: sPtJ:/_D
CONTRACTOR: ADDRESS:
CONTRACTOR REGISTRATION NO: (~-:<:. I (') P-.
PROJECT S,UPERVISOR: -r;-,~ J.-'/oi; {..~
EXPIRATION DATE:
REQUESTED PERMITS:
INSPECTIONS REQUIRED:
o ENCROACHMENT PERMIT NO: ............................... n
VALID FOR SIXTY mOl DAYS FROM DATE OF ISSUANCE
o CUT STREET 0 BORE 0 OTHER
o DUST CONTROL ITYPE OF CONTRoLI
o CONSTRUCTION. STORAGE. STAGING n
Om- n
o ASPHALT DEPOSiT....,..... .............. .......... ..'................."........ ...... ...... .......... .......... .......,..'
n
TVPF OF l':ECURITY DEPOSIT
o BLANKET SURETY BOND 0 SURIITY BOND 0 CASH / CHECK
D CURB CUT PERMIT NO: .................... FT. n
IN"PFCTlnN. CURB / APPROACH AmR FORMS ARE ERECTED BUT PRIOR TO POURING CONCRETE.
VALlO FOR 180 DAYS FROM DATE OF ISSUANCE.
o SECOND DRIVEWAY (SEE SEPARATE APPLlCA liON)
~ SIDEWALK PERMIT NO: .................... FT.~L C; 0
VALID fOR 180 DAYS FROM DATE OF ISSUANCE.
~ NEW 0 REMOVE / REPAIR 0 PAVE PLANT STRIP
o SETBACK 0 CURBSIDE 0 LENGTH
If'lFfErT[I~I. ""OEWAlK I DRIVEWAY FOR ALL CONCRETE PAVING WITHIN THE STREET RIGHT OF WAY, TO BE
MADE AFTER ALL EXCAVATING IS COMPlETE. AND FORM WORK ANO SUB-BASE MATERIAL IS IN PlACE.
D SANITARY SEWER CONNECTION PERMIT: ................ n
VAllO FOR SIXTY (601 DAYS FROM DATE OF ISSUANCE
o TO STUB 0 MAIN LINE (EASEMENT.R/w) 0 OTHER
o STORM SEWER CONNECTION PERMIT: ....................n
VALID FOR SIXTY (601 DAYS FROM DATE OF ISSUANCE'
o CATCH BASIN I BUBBLER 0 STUB 0 MAINLINE
PROOF OF INSURANCE' $500,000 MINIMUM
o ATTACHED 0 REOUIRED AMOUNT
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so~ ? ;:z; P, ~ /7 ;? J
TAX MAP: / I (')~ /'-;' (') 0
TAX LOT: (I II
,
STATE:
PHONE: 7 a<o - cc<34-4-4
o IZ ZIP: 974- '7 )
PHONE:
1- {("'.-~/
PHONE:
APPliCATION FEE I DEPOSIT ACCOUNT NO:
o $20.00/
0$
0 $
0 $
0 $
0 $
0 $10.00+$.15/FT.
0 $10.00 + $.15IFT. J (0 , 7 c:::-
o $5.00/.
o $5.00 I
TOTAL DUE: $
TOTAL DUE WITH PERMIT $
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 REPLACEM'ENT MATERIALS TO BE'UTILlZED:
TYPE OF DUST CONTROL TO BE UTILIZED:
NAME OF DTHER UTILITIES IF THIS IS A JOINT PROJECT:
WARNING DEVICES TO BE UTILIZED:
FROM DATE:
TO DATE:
DEPTH:
BORE:
BACKFILL MATERIAL:
/
.....
TIME:
TIME:
HEIGHT:
DESCRIPTION:
Ad....aneo signing and work zono protoction to bo in eompUaneo with tho Manual on Uniform Traffic Control Dovieos (MUTeD).
REVISIONS 8/24/95
FORM '116
WORK SHALL COMPLY WITH CHAPTER X ARTICLE 5 OF THE CITY CODE. CONTRACTOR TO COMPLY WITH MUTCD .
l
PLAN REVIEW COMMENTS f SPWL INSTRUCTIONS: .
RESTORATION WORK SHALL BE IN CON~ORMANCE WITH EXISTING CITY CODES AN!"iN ~MPLlANCE WITH CURRENT
STANDARD SPECIFICATIONS. EXCEPT AS NOTED BELOW.
_ 001 Backfill with ~.. minus rock.
_ 002 Compact every 18" loose depth.
_ 003 Requires compaction with a steel roilier.
_ 004 A.C. to match the greater of existing depth or 4".
005 All cuts sealed for final inspection.
006 Temporary patch may be used at the end of the day.
_ ,007 Signing and Zone protection to comply with MUTeD
_ '008 Cut concrete only on score lines or cold joints.
_ 009 Sidewalks and driveways min. 3,OOOpsi.
_ 010 Curbing min 3.50Qpsi I No patchwork less than 3'.
_ 011 Meet min. requirements on curb cuts. Spfd. code.
012 Restore planted areas, Spfd. code 206.3.05
_ 013 Spec. to Bore I Jack f No A.C. cuts.
_ 014 Mechanical compacting required.
_ 015 No patchwork allowed.
_ 016 Lateral cuts to have control density fill.
_ 017 Cuts to be polymerized crack sealed for final inspection.
018 ~ininum 2" crushed rock %" minus.
019
020
021
022
023
024
025
026
027
:1- 028
029
030
031
032
033
343
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-
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Comments:
..
'.
Minumum 4' clearance at any point, swing-away.
Concrete minimum 4" depth, 3,OOOpsi.
Trench to be "T" cut.
Needs State I County permit.
No above ground enclosings in sidewalk or handicap ramps.
Diamond cut A.C./Concrete value boxes to grade.
Fresh Oil signs I 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 excavatiiln.
Core drill main line, insert tee, 2% min. grade.
Must comply with the provisions 01 OAS 757.541 to 757.571.
6" Circular hole/H20-Vac.
YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
!ia"'CUR8 CUT AND SIDEWALK INSPECTIONS CALL 726-3769 (RECORDER) STATE YOUR DESIGINA TED 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.
o SANITARY SEWER. STORM SEWER. ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
726-3761. '
SIGNATURE:
AMOUNT RECEIVED: J ((') . "7 c:::;-
RECEIPT NO: e L C \ 0 '=?
DATE PAID:
RECEIVED BY:
f - fA - 9 Co ,
_ 4~~? ,~J ~oJ)~
By signature, I state and agreel 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 Drawmgshand 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
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 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 "ns will remain on the site at all times during construction.
Signature ~ //I^ A~ ~ Date / ~ If -'10
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 DRAWER.
INSPECTION: DA TE:
INSPECTION: DA TE:
WORK IN PROGRESS
AT TIME OF CDMPLETIDN:
ELEVENTH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DATE:
.-
City uf Springfield
- 225 ~ifth street
St.\r'ingfield, DR 37477
(~G3) 72&-3753
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7r~~saction nvnlber' 020i09
Janua~Y lS, 133b !:~4?M
~ Heceiveo -rf"'on,-; VIEGH ?ACl?IC
Con t.r.;~.ct, IOIJJf\
Add~ess~ 3377 S~ 21ST AVZ
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1l)ank yOU, Gec~ge ~.
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