HomeMy WebLinkAboutPermit Sidewalk 2019-04-05Driveway/Sidewal k Permit Application
Ary of Springfield
Application Date: | _ELD
Permit Number
225 Fifth Street, Springfield, Oregon 97477
Transportation & Engineering Section, Public Works Department
Phone: 541 726-3753
lssue Date:
SITE INFORMATION
Location of Work:
Applicant:
Address: \t fi( rTjf )rlrd\ \ { at
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OREGO
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City:Sffrrg.f,e \r'\ state:D(- zlP:cl-r r{ r -r Tax Map
Tax Lot
Subdivision
Owner:
Address:
City:
4O.nr- A<. ,rtt-f,r.rO Phone:_______l
State:ZlP:
REQUESTED PERMITS:
l: Sidewalk Amountofsidewalkin excessof 90feet_
[- Sidewalk Repair
E Curb Cut/Driveway: Number of Driveways I
E Multiple Permit Discount each: (Maximum 2)
Ivlulti permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
l- s% Technology fee
l- Proof of tnsurance: 5500,000 Minimum if work is done by property owner'
Fees
@50.11 SF
51 21.00 l st Cut X 565 2nd Cut
ILL, b{
Total due with permit 5
r Facility Meets 201 1 PROWAG For ADA Compliance
CONTRACTOR'S INFORMATION
O u.l tt -o Phone:Name:
Address:
City:State:ZIP:
Project Supervisor Phone:
INSPECTIONS:
An inspection request should be made prior to pouring concrete, after the ProPosed work has been formed and made ready to pour'
Curb cut and sidewalk insPections call: 541 726-3769 (recording)State your designated City job number/permit number, job address,
Owner's name, and phone number. Requests
type of inspection requested, and when you will be I
received before 7:00 am will be made the same day,
ready for inspection, Contractor's or
requests after 7:00 am will be made the nextworking day. lnspections are to be
called in after excavations are made and form work is in place,but prior to pouring concrete.
ng Couto call:hours n9.
Laneare
SIGNATURE:
Amount Received:Date Paid:
Receipt No. Received BY:
By signature, I state and ,g,"uGuarh*" *r.fully examined the completed application and do here by certiry that all information herein
is true and correct, and I further certiry that any and all *ork performed shall bedone-in accordance with the Ordinances of the City of
Springfield applicable clty yanaari sp".in.ations and arawi-ngs ana the laws of the State of oregon pertaining to the work described
herein, I further certify that only contractors and employees *io are in compliance with ORS 701'055 will be used'
The City may inspect the work site described in this permit at any time during a one year.period following receipt by the city of notice of
completion ofthe described work and specify, at the City'r rot" dir.r"tion, any additional restoration work required to return the site to a
standard acceptable to the city. The permittee witr ne notneJin *iiiing of any work required and will have thirty days (30) from the date
of the notice to complete the work not completed ut tr,u "ni oiitt" tt'i.i aavs *irl be performed by the city and the costs will be billed
to the permittee.
i funf,", ,gra" ,o ensure that all required inspections are requested at the proper
tfr" .pp.r"a set of plans will remain on the site at all times during construction'
time that proiect address is readable from the street and
I
Signature
Date:
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