HomeMy WebLinkAboutPermit Encroachment 1998-8-13
2 6 'FIFTH STREET
SPRINGFIELD. OREGON 97477
ENGINEERING DIVISION
OFFICE TELEPHONE (503) 726.3763
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ENCROACHMENT PERMIT
NUMBER:
PERMIT NUMBER: =Jf(' /04-<D,
INSPECTION LINE SEE INSPECTIONS ON BACK SIDE .
APPLIPATION DATE: sr.-/~-9J? .. !pATE ISSUED:
. . LOCATION OF WORK . t.to ~\lliJ'" _ __
APPLICANT VS1V,/ ~~{)N 177 JC,!dIh a? PHONE &-. 'l?R )('X"7/ ___ \ "-
SITE ADDRESS: :So URN 14l All') Q.fl.:::..'>C--'.12.f<> ~;~~~O/q6f RlIIV~AXMA":0/7-().."" -3~-:2/)
CITY:St"P..IJJ~t::Iln..D STATE: "R. ZIP:- TAXL : 1..:2.. 0 l'"l
SUBDIVISION: -bL R ,="Q"""I/ ..... ~
OWNER: Vt:RN ~,a-^l~f'l^, .PHONE: l..'i?~ 'BRC!7?
ADDRESS: _940 J.luJV CfC1 A/ CITY: P-V~LS STATE: .....Q.R ZIP: 97s,1,I');(
CONTRACTOR: wAWt:n.J l'1lAiQT: ADDRESS: pt').1'VlJr LLJ fI::2.. '7 . PHONE: ht)7....~22
CONTRACTOR REGISTRATION NO: ~O/...J..q7 EXPIRATION. DATE: 7-~/- 1'Jt')
PROJECT SUPERVISOR: RDBt::!1<r /, I,qLn~ PHONE: -1:,r>/,&>1...:z.2
~-17- '15{
REQUESTED PERMITS: INSPfC1lONa fll!OUl"'h
ij[f~NCROACHMENT PERMIT NO: ............................... n
'!.....AL.' FOR SIXTY 1e01 DAya PROM DATI 0' tlSUANCI
f:4"CUT STREET a BORE a OTHER 0
a DUST CONTROL (TYPE OF CONTAOU
Aftlll.JC:AT1OH RI, DUOS"
ACCOUNT NOI
o *80.0~
0*
a CONSTRUCTION. STORAGE. STAGING
a OTHER
n
n
O.
0*
Q*
Q ASPHALT DEPOSiT......................................................................................................!.....
mE.!'~c:~rIIRITY DEPOSIT
a BLANKET SURETY BOND a SURIITY BOND a CASH / CHECK
eCURB CUT PERMIT NO: ................;... FT._~ 0
INOll'l'!TInN. CURB I APPROACH AF1"ER FORMS ARE weno BUT P'fUl.J11 I U i"'QURlNQ CONCRfTL
. VALlI FOR 110 DAV. fllDM DATI 0' ISSUANce.
a SECON'O DRIVEWAY ISEE SEPARATE APPUCA nON!
~DEWALK PERMIT NO:.................... FT.
VAll) ~R 110 DAYS FROM DATI 0' ISSUANCI.
a NEW a REMOVE / REPAIR a PAVE PLANT STRIP
a'SETBACK a CUR8SIDE a LENGTH
.""t:n,..Tln..... !:IOEWALK I DRIVEWAY FOR AlL CONCRm 'AVIHQ WI1'H!H THE STREET RIGHT 0' WAY. TO BE
_ ~ AfTER AU VtCAVATlNG II COMlUTl. AND FORM WORK AND IUe.eAIl MATERlAL IS IN PLACL
!..::rSANITARY SEWER CONNECTION PERMIT: ................ n
VALl) FOR SIXTY 1101 OAya MOM OAT! w: ISSUANCe:
~ TO STUB a MAIN UNE (EASEMENT.RiWJ a OTHER .
llfJsTORM SEWER CONNECTION PERMIT: ....................n
VALl) 'OR SIXTY 1101 DAYa MOM DATI ()I: ISSUANCI .
a CATCH BASIN / BUBBLER aSTUB aMAINUNE ()JeEP HoLt.
""nn~ n~ ''''''''''~ $500,000 MINIMUM
. a ATTACHED a REQUIRED AMOUNT
O.
o .'0.00+$.'6/FT.
I if. ro
n
Q $10.00:t-$.16/FT.
~6.00 J .
. <5.00
Q $6.00 I
DESCRIPTION OF PROJECT:
PERJPD OF USE OR TIME OF CONSTRUCTION:
c:r PLANS (TWO SETS) ATTACHED .
AREA: LENGTH: WIDTH:
TYPE OF WORK: CUT:
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTILIZEO:
SURFACE REPLACEMeNT 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:
J '~i1- .. Advanc. IlgNn; Ind work zone .protlctJon to b.ln compllanc. wI\Jl~" M,nual on UnI!otm TraUlc ConV'Ol DIYlc.. {MUTeDI.
DESCRIPTION: ",,:v'TI.HlJliJJ~U rLd- .~(\AUJJeL (lMA <rhnm 5-PIMV e-v-k1i16JfT/,1A) AdOID.(l.1l
I .urklLh Jlt J I" I .
,,\ ) ~\ y )<, . ( J:=.,. \( )'n
TOTAL DUEi-.
TOTAL DUE WITH PERMIT .
lq,~O
/UfJ
FROM DATE:
TO DATE:
~/IIICj,?"
\ I II JOl <:;(
. bEPTH:
TIME:
TIME:
HEIGHT:
BORE:
BACKFILL MATERIAL:
WORK SHALL COMPLY WITH CHAPTER X ARnCLE Ii OF THE CITY COD~ CONTRACTOR TO COMPLY WITH MUTCD.
MVISIONS 8124/86 FORM , 118 '
,
PLAN REVIEW COMMENTS I SPEaAL INSTRUCTIONS:
RESTORAnON WORK SHALL BE IN CO lANCE WITH EXlsnNO CITY CODES AN.MPUANCE WITH CUf\R r.
STANDARD SPECIFICAnONS, EXCEPT A OTED BELOW.
. 001 8IckflH WIth .. mlnUlIOCk.
". 002 Comp.ct ev.ry 18' 100.. d.pth.
. 003 R.qulro. oomp.ctlon with. at..1 ro1l111.
. 004 A.C. to m.tch the Oro.tll 01 e.llllno dopth 01 4".
. 005 All out. ...I.d 1001In.IIMp.oiton.
. ooB. T.mporary p.teh m.y be u..d .lthe end 01 tho d.y.
. 007 Signing .nd Zonl protection to comply with MUTCO
. ooB Cut eenerot. only on .eoro IIn.. 01, cold lolnt..
. 009 SId.w.11eI .nd drtVeweye mln. 3,OOOp.L
. 010 Curlllno mln 3,BOOpall No pllchwor1< I... th.n 3'.
. 011 Mell min. requtremenu on cur1l CUle, Spld. cod..
. 012 R.llore pl.nt.d.ere.., Spld. code 20B.3.08
. 013 Sp.e. to Bore I J.ek'l No A.C. cut.. .
. 014 Mochenle.1 comp.ctlnO reClUlred.
. . 018 No p.tehwor1< enow.d.
. OtB Latll.1 cut. to h.vo control d'MItY 1111.
017 Cut. to b. polym'~Zld crack ...I.d IOIlIn.lln.poctlon.
Q. Ot8 Mlnlnum 2' cN.hod rock.' mlnu..
- 01S Mlnumum 4' cl..renc. .t.ny point, .wlno..w.y.
.
. 020 Concr.t. mlnlmum 4' d.pth, 3,OOOp.I.
. 021 Trench to be "T' cut.
- 022, NOId. St.t. I County pormll.
- 023 No ,bov, ground Incloslnglln Ild,walk or hendlc,p ramp..
- 024 Ol.mond cut A.C.teoneral' v.lu. box.. to orado.
- 026 Fr..h 011 .Ion. I Grodod. ~
- 02e Comply wlt~ A!n"lc.~. wllh Ol..bllltl.. Act.
. 027 Concroll .I.b., 72hr.. cu~ng 11m., 4600p.l.
- 02B Concrlle .I.b. require Joint ...1 m.t.~.I.
. 029 O~vow.y ..qulto. dow.l. ov.ry Ie".
- 030 Submit tr.me control plan prior to excavatIon.
~ :: Notify Tretllo Olvl.lon b.fo.....xc.y.tip,;.
. Cor. ~rlll mlln,lIn'f Inll" tee. 2% min. grad..
. "g~~ . MUll comply wlth"tho'provl.l"n"of ORB 757.641 to 757.871-
e' Clrculll hol.1H20.v.e.
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Comments:. .'
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YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS BEFORE DIGGING
INSPECTIONS:
'0
CURB CUT AND SIDEWALK INSPECTIONS CAll 726-3769 (RECORDER) STATE YOUR DESIGINATED CITY JOB
NUMBERIPERMIT 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 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:
AMOUNT RECEIVED: 14- ~
RECEIPT NC3: 0, I \ () ,
io
DATE PAID:
RECEiVED BY:
<6 - rr -cr~
v'VIC; I /-
By slgneture, I etete and egree~ thet I have carefully sxemlned the completed eppllcetlon end do hereby certify that all information
hersln la tl\le end correct, end further certify that any and ell work performed shall be done In eccordance With the Ordinances of the
, City of SPringfield, eppllceble Ity Standerd speclflcetlons end Drawlngshand the lews of the Stete of OrsJlon pertaining to the work
described hersln. I further certify thet only contrectors end employees w 0 are In compllancs with ORS 701.055 will be used on this
, project. .
The City may Inspect the work ,:te described In this permit et :any time during e one year period following tho receipt by the City of
notice of. completion of the described work end spel;lfy. e\ the City's sole deseresslon, eny edditlonel restorstlon work required to
. return the ,lte to e atenderel eccepteble to the City. THe Permittee will be notified in writing of eny wprk required end will heve thirty
" dsyel30\ from the date of the nollce to complete the work. Work not completed et the enCl of the thirty deys'will be performed by the
Clfy end the oosts will be billed to the permittee.
, I furthor egree to ensure thet ell required Inspections are rsqu4sted at the proper time, thet project address Is readable from the street,
and the approved eet of plens will remeln on tho site et all times during construction.
, . . .
Signature
Dete
VALIDATION:
o TRAFFIC REVIEWED BY:
o ENGINEERING REVIEWED BY:
, 0 MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
: FOR SIDEWALK AND CURB CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT DRA WER.
INSPECTION:
:, INSPECnON:
WORK IN PROGRESS
AT nME OF COMPLETION:
ELEVEN:rH MONTH:
DEPOSIT RETURNED:
DATE:
DATE:
DATE:
DAT~:
DATE:
DATE:
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