HomeMy WebLinkAboutPermit Encroachment 1998-1-20
-.. CITY OF SPRINGE' :LD . P""1MIT APPLICATION
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\ 226 FIFTH STREET .... _NaPlILD
. SPRINGFIELD, OREGON 97477 . ~
I 'ENGINnRING DIVISION""" . ',"" ,.,.....'.1 .
, OFFICE TELEPHONE (503) 72e.375~ 'J:" ..... ~ .
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ENCROACHMENT PERMIT".'. "
NUMBER: .
PERMIT NUMBER: . 9'1: CJU7 )'
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\ INSPECTION LINE SEE INSPECTIONS ON;BACK SIDE'
APPLICATIONDATE: ;~-ZO--4 0
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-LOCATION OF WORK
APPUCANT !-/.AR-DItC.C~OLtz..~1
SITE ADDRESS: ~q6<6 )/I'W.s711fIlL GT
CITY: c;:;;? 'STATE:,1I~ ZIP: eJ?C/77
SUBDIVISION:
OWNER: . ~1~~f) U~7'/ce.... 1-It1i'tc<) .PHONE:
ADDRESS: ~7~ ...". '/l ' CITY: .~/ STATE: eJlL
CONTRACTOR: 1-1~/2.f)JUkiL~()t-L'/jo/ ADDRESS: ,a b lC b3b (JP~~
CONTRACTOR REGISTRATION NO: ?9Lf-cr&7 EXPIRATION.DATE: ;:Z);1 jq'tJ
PROJECT SUPERVISOR:
DATE ISSUED: ". /-- z(.; :Vf
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PHONE
-1i~ -~~7
,TAX MAP:
TAX LOT:
/.7-D'2.. ::s (J =>",c,t
. /0 :?r,~_
?7"l~ 4<'CO'?j
ZIP: .
. PHONE: "ll?r-<&.r7
PHONE:
g'1<;----1'307
REQUESTED PERMITS~
Cl ENCROACHMENT PERMIT NO: ............................:.. n
VAll) FOR IIXTY l80I DAVI FADM DATI ClI' IIIUAHCI
Q CUT STREET Q BORE ,. Q OTHER n
Q DUST CONTROL !TYPE Of CONTROU
INS ...". .. RlQUIRllh
Q CONSTRUCTION, STORAGE. STAGING
QOTHER
n
'l
Q ASPHAL T DEPOSIT....:":.........!.............!.........................................................................!.....
TYPE OF SI;CtJRtTV nl;POSIT
, Q BLANKET SURETY BOND' J. Q SURlITv BOND Q CASH I CHECK
~URB CUT PERMIT.NO:..m~..:..;.....:... FT. ~ Q .
INltHMIt'lM, CURl I oVPROAQt NT!R fORMS ARlIR!CTtO BUT r'R.lOfl TO POURlNO CONCRnL
. VALl) POR 110 DAVI fllOM DATI ClI' IlSUANCI,
Q SECONii ORJVEWA V. (SEE SEPAIIA TI APPUCATlONl
Cl SIDEWALK PERMIT NO:.................... FT.
VALl) PeR 110 DAYS MOM OATI OJ IIIUAHCL
Q NEW Q REMq"E I R.EPAlR C PAVE Pl.ANT STRIP
Q'SETBACK Q CURBSIDE Q LENGTH
ItJt_I"'rW'II\I, tlDfWAUC IORrVIEWAY FOIl AU. CONCMTI 'AVINQ WITH1H nca STRUT RIGHT 0' WAY, TO Df
MADI AnUl AU IXCAYATlNQ 18 COMPUTI , AND PORU WORK AND IU808AI1 MATINAL IS IN PL.ACI.
o SANITARY SewER CONNEcTtON PERMIT: ................ n
VALl) POR IPCTY CIOJ DAYS MOM DATI OP IIIUANCI
Q TO STUB Q MAIN UNE lEASEMENT.fl/Wl Q OTHER
o STORM SewER CONNECTION PERMIT:...................... n
. VALl) POIlIlX'rt rtoI OAva PROM DATI OIl IIIUAHCI .
Q CATCH BASIN t 1lUBBLER- (Q STUB. Q MAlNUNE
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PRnnF "F ''''''IRANCE' 8600,000 MINIMUM
. Q ATTACHED Q RE(lI,lIRED AMOUNT
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n
a $6,0'0 I .
a 86.00 I
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DESCRIPTION OF PROJECT:
, TOT~ D!Ji;-. '
TOTAL DUE WITH PERMIT.. .
., -
:p I"i.. 'it)
",' /2, ----IQ
'v
.. ..'.: . .1., ..I'..I! ' 1>
PERIOD OF USE OR TIME OF CONSTRUCTION:
Q PLANS (TWO SETS) ATTACHED
AREA: LENGTH:
n:PE OF, WORK: CUTl
OTHER:
EXISTING SURFACE MATERIAL:
BACKFILL MATERIAL TO BE UTIUZEO:
SURFACE REPLACEM'ENT MATERIALS TO BE UTILIZED:
TYPE OF DUST CONTROL TO BE UTIj.IZED: ';'::, .
NAME OF OTHER UTILITIES IF THIS IS A JOINT PROJECT:
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WARNING DEVICES TO BE UTILIZED:
MY..... aIgnIng end work _o.protoctlon to be In "mp/lol~O ";,;. u,. ,.;...... on UnllO<lll TroUlc Control DoYle.. IMUTCDI.
. FROM DATE:
TO DATE:
....
J.I', '....
,TIME: .
TIME:
HEIGHT:
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,wIDTH:
,'.1
DEPTH:
BORE:
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. BACKFILL MATERIAL:
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DESCRIPTION:
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WORK SHALL COMPLY WITH CHAPTER X ARTICLE 6 OF THE CITY CODe. CONTRACTOR TO. COMPLY WITH MUTCD "
REVlSIOHS 8/24/81 fORM.' 110 .'
.
, ;";~~~~;~;;;~~~~;~:~~crrvco~~'~~~PUAN~~wrrH CURRENT. .. ...j',
. 001 BackflllWltllI'm1nlll'rock.. '. 0 '018 M1Murft4'cl..ranc..tI~YPOlnt..wlng..w.y. ...........:...-.
.:'. 002 Comp.ctlv.ry lS'loo.. d.p!h. . . 020 c:-.II minimum 4'.d.pth. 3.COOpal.
003 R.qulra. compaction ,wfth . .t.., rolll.,. . 021 TranCh to III 'T' 01lI.
o 004 A.C. to milch lht gra.t., of .xltt!ne d.pth 0' 4'. 022. N..d. SI.III CountY p,,",~,
. .005 All O1lI....I.d for I1ntIlnap.oiIon. .. .J 023 Nubov. ground..ncIoalnga In ald,w.lk or h.ndic.p ramp..
. 008. T.mporary p.lch may b. llI.d IIlht .nd 01 Ih. d.y. ; 024 Diamond 01lI A.CJConcrat. v.1uI box.llo grad..
. 007 Signing end zonl prollCllon 10 comply with MUTCO . 025 Fralh on algna I G,.d.d.
. ooa CUI oonctll' only on oeor. 11n.. 00: cold lalnll. . 028 Comply wflh AmlrlcIna wflh Dlllbllltl.. ACI,
ooa 81d.walkl .nd drIV.w.y. tnIn. 3,COOp'" , . ,027 . Conctm allb.. 72hra. curing tlm., 45oap.i.
':,:' F 010' cUrbing m1n".Soeptll No pIIchWort I...th.n 3'. : 02S Concrall al.bI raqulra Jolnt...1 mll.~.I.
.011 MOil min. raqulram'nII on CIltlI 01lII, Spfd. cod.. . 028 ~way raqulra. dow." ...ry 18'.
. . 012 R.llora pl.nlld..'.... Spfd. cod. 208.3.0S . 030 Submlllt.fflc control pl.n ~or 10 "Clv.tlon.
. 013 Spec. to Bora I J.ck I No A.c. CUll. , . . 031 Notify Trafl1ci'DMtlon IlIlora "..v.tlpn.
. 014 M.chlnI'" comp.ctJne raqulrad. . . 032. eora d~D main 1Int.1nt1tt I.., 2'!l. min. gr.d..
. 015 NOpllchworfclDow.d.' . 933 Mualcomplywflhlhtprovl.lonaofORS757.54' to 757.571.'
. 018 __ Lot.ral CUll to NV' conltol d.nallV fill. . 343 8' CItcuI., hoIl1H2Q.V...
017 CUlt 10 III pclym.rlzed crack ...I.d for fln.llnap.Clion, .J
c.. .01B Mlnlnum 2' cru.h.d,rock I' mlnlll. ... '.
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Ccir;nmeriti:
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YOU ARE REQUIRED TO CALL
THE LANE UTILITIES COORDINATING COUNCIL'S
"ONE CALL NUMBER" 1-800-332-2344
48 HOURS 8EFORE DIGGING
" INSPECTIONS:
"0
CURB CUT AND 81DEWALK INSPEcnONS CALL 728-3789 (RECORDER) STATE YOUR DESIGINATED CITY'JOB
NUMBERlPERMIT 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 WO~K IS IN PLACE BUT PRIOR TO POURING CONCRETE.
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o SANITARY SEWER, STORM SEWER, ENCROACHMENT PERMIT AND OTHER INSPECTIONS CALL CITY MAINTENANCE AT
728-3781.
SIGNATURE:
AMOUNT RECEIVED:
RECEIPT NO:
/:2 7{)
:215 S2? h
'(.
DATE PAID:
RECEIVED BY:
/- 20 ~'1Y
0.0 ~f
By 'Igneture, I .tate and agree~ that I have car.fi.llly examined the comp'leted application and do hereby certify that elllnformetion
hare n Is tt\le and correct, and further certify thetanv and ell work peHormed Shell be dpne In Iccordallce 'wlth the O,dlnences of the
. City Clf Sprlngfleld. applicable Ity Standard spaClflcatlons end Drawlngehand the IIWI !If the State of OJ'llllon pertaining to the work
described herein. I furthe, certify that only contractore and employees w 0 alll In compllence with ORS 701.055 will be used on this
. project. " , . '.' . '. , . tli,!;. .
The CItY mey In'l1ect th~WO'k elte descrlbed In lhIsl!8tmlt at:eny ~me during e one vel' perlod following the ,ecelpl bY the City of
notice of. completion of' e descrlbed work Ind specify, It th, City I e(lle de80'Is810n, InY Iddltlonll resto'ltlon work ,equlred to
. ~turn the ,Ite to I stln I~ Icceptlbll to the City. Tlie Permltte, wID be notified In writing of eny W(lrk r,qulrad and will have thirtY. .
'. eys (301 from the def' 0 the notice to cOlllplete the work. WO'k not complated 'at tha en(! of the thirty day.' will be performed by the
.' ;Ity and tha OOS18 wll be ,lIIed to the permittee.
I furtho, ag~e sure th'et all required Inspections ara re'lullstad at the prope' lime. that p,oJect add,ess la ,eedable from the street,
end ,the ep, ved .t of ra~'lwlII r'raln on the ~t ell t.mes du,lng construct on. . ' .
Signature . .--Y ' W' ,k{ ..../ - . Date I.....?-..... - fl?
VALIDATION:
a TRAFFIC. REVIEWED BY:
o ENGINEERING REVIEWED BY:
. 0 MAINTENANCE:
o PERMIT ISSUED BY:
DATE:
DATE:
DATE:
DATE:
, , FOR SIDEWA~K AND CURB ,CUT PERMITS PLACE A COPY (COMPLETED) IN PERMIT DRAWER.
. INSPECTION: DATE:
'. INSPECTION: DATE:
. . WORK IN PROGRESS' DATE:
AT TIME OF COMPLETlON:- . ~A T~:
ELevEN:rH MONTH:', ." '.DA TEl "', .
DEPOSIT RETURNED: DATE:\ ",
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