HomeMy WebLinkAboutPermit Encroachment 2019-07-10Print Form
Application to Work in the Right of Way
em.il or print .nd bring to Public Works City Hall.
You wlll need to cometo Public Works, Clty Hallto process permlt.
City of Springfield
Oncethe has been approved, o permit will be issued
will need to complete application, save as, then attach to
ication can be emailed to '.gov,225 Fifth Street
Springfi eld, Oregon 97 477
Engineering & Transportation Services Division
Phone (541) 726-3753
Step 1-Location of Work
Who is filling out the application?
ln this section, you will need to identify the Applicant, Owner of the abutting property, and the Contractor, if applicable.
Exa nr pl e:
John Doe is the owner of the abutting property. You would need to put name, address and contact information.
Jane Doe is the Applicant. This is the person filling out the application and filing for a permit. You would put in the contact information.
Utility Doe is the utility company that is doing work in the right of way and would be an considered an applicant. You would put in the
contact person's information.
Contractor Doe is the contractor who will be doing the work in the right of way. You will need to put this contact and license information.
Site Address or Location
Applicant:
Email Address:
Owner:
Address:
City:
Contractor:
lnsurance
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Tax Map
Tax Lot
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Phone:
Phone:
Expiration Date: 3 * I -( 4czo
Phone: -fq/-?tq-tt1 3
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State:ZIP:
Contractors Registration (CCB)
Project Supervisor, J Og
#:
Xproof
of tnsurance, minimum 5500,000 coverage limit
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Utilities
Does your utility company have o franchise ogreement or license with the City?
Please identifu which type of agreement you currently have with the City. l- Franchise Agreement f License
Name of other utilities if this is a joint project :
lntent of project for other utility who will
own any facilities placed in right of way:
Step 2: Description of Project
What type of work do you need to do?
ln this section you will describe the location, intended use, and what measures you are implementing, such as traffic control
measures, dust control measures, and types of backfill material to be used.
-Provide the start and end dates, start time of day and end time of day, of your pro.ject. lt is important that you give
time of day that you are requesting for your project work. There are codes and inspections that are time sensitive.
-ldentify your method of intrusion into the surface of the right of way, such as cu! bore, or drilling.
-Describe the surface area length, width, depth, and height of your project.
-ldentify what type of surface material is currently there, what you will do with this material, what is the replacement type
of surface material you will use, and what type of backfill material you will be using.
-Any required separation from other facilities.
lfelacing new facilities in the right of way
[- Repairing/maintaining existing facilities
Project
Description:
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Period of use or time of construction: 7am to 6 pm only, unless it's an emergency.
From Date:t-t-Iq. roDate: 1-t-I1
DailyStartTime: f( o"-,,,a. DailyEndTime:
SJOP: Auuet q-qestions nex!
y Are you working in the right of way or connecting to City facility? lf yes, continue at Step 2a: Work Site Area
Are you storing material/objects in the right of way other than during hours of work? lf yes, continue at Step /t c)
3: Submit a Work Plant-
Step 2a: Work Site Area
( Cr, .l-- Bore other:
Lens\h (D' Depth v width Ztl" Height
Existing Surface Material:4+)"A.lt
Surface replacement material to be utilized:lr"
System Connections to City lnfrastructure
Directions: Submitplansthatidentifyindetail thescopeofworktobeperformedintheCityrightofway/easement. Theworkshall be
performed by a licensed contractor that is aware of wastewater spills/overflow reporting requirements and City design standards. Your
permit shall have specific instructions from the City inspector on how to perform the work. Keep these instructions on site.
T Wastewater Connection T Stormwater Connection
l- To Stub [- Catch Basin/Bubbler
pJrlain Line [- Stub
f Other: l- Main Line
Description:
r r,
ZaTrua'/.t'l'i.lJ
C
Safety and Environment
Air Quality
Type of Dust Control to be utilized:
vol are re-quired to cail, rhe t-ane utilities Coordin-atlng council\ rone call l{umbe/
811 or1-800-332-2344
48 hours before digging.
Stormwater Pollution Prevention
Directions: The City is required by Federal and State law to monitor the discharge of construction stormwater and site runoff. Applicants
shall develop and submit a Stormwater Pollution Prevention Plan (SWPPP) that minimizes to the maximum extent practicable the
discharge of sediment and other pollutants to the public stormwater system. Call LDAP with questions, 541 '/ )6 5'i89.
Listed below are some of the most common issues on right of way construction projects. How will you address these items on your
SWPPP? Please be aware that each project is unique and may present challenges not addressed in this set of examples.
f- Dewatering I/ Soil erosion [- Hazardous material storage/spill prevention
k sa*cut rlrrry runoff ff site runoff/sedimentation/r-
Wastewater Spill/Overflow Prevention
Directions: City policy requires that all work performed in the City right of way/easement is in full comPliance with DEQ and EPA
regulations. No spillage of raw sewage shall occur during construction, including spillage in an open trench or excavation. The contractor
shall take all reasonable precaution to avoid spills and shall immediately notify City of Springfield Maintenance 511 / ) (> 36 | 5 or
541 176 31(jl: After lrorrrs l nret<,eircv Rcs;:olse learrr 5'1'l 951 1428 inthe eventofaspill.
Plan submittal for Wastewater main line work
l- Bypass pumping [-- Temporary plugging of sanitary main
Traffic Control Plan Criteria for City of Springfield Traffic Control Plan Submittals
Directions: You will need to submit a Traffic Control Plan, which will need to be in compliance with the Manual on Uniform
Traffic Control Devices (MUTCD) and Oregon Temporary Traffic Control Handbook.
Plan Subminal requirements:
Submit your Traffic Control Plan (ICP) with the following information on 8.5"x1 I " or 1 1 "xl 7" paper. Fill out and submit this form with
your TCP.
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Backfill material to be utilized:
TheTCPshatlbealegiblehanddrawing,oracomputelaideddesignwiththefollowinginformation:
i,#',1'llrTli*e north arrow, ro"9 "".-"1ll.ily::l,il';:Iil:i:Ts
Points' curb lines' the work zone' and anv special reatures such
as buildings, access Points' sig
Where will the TCP be active?Thiscanbealinedrawingoftheworkzone(s)and/oramapthatclearlyindicateswheretraffi<contro|Location:
Attachments of the aPProPriate traffic control diagram(s) as shown in the current MUTCD and/or the ODOT Oregon Temporary Traffic
Jevices will be Placed, including spacing and cone taPers.
Control Handbook that reflect the work zone maY be included as a standard reference'ODOIs Traffic Control Handbook website: u4Lu4
Control Plan attached in email to Land Development;LDS6sprinsfield-or.sov 6nf fl eI S
No Traffic Control PlanTThere are no traffic issues with this
m a n
ldentify extent of excavations
or bore locations.
What kind of work Plan do You need?
Y*, *il| n""d to submit a copy of the work plan' which includes:
$ite location and vicinitY maP T/ \'ihclude North arrow.
- outline limits of disturbance/ Show location of utilities within right of way. ldentify pipe
I of work area. J- iize and type, mainline connection location, and
f identifystaging/material connectiontype.
*",ur,"":t",1::;J::t"-.,emairtoLandDeveropment; sencr roLDsg,springtierdor.gov. Referencesirerocationandnameinsubiecrline'
*construction of ADA ramps or other ADA facilities require submittal of detailed topographic survey and design sheets stamped
by a professional Engineer licensed in the State or oregonl i.tign or non tacilities shall at a minimum meet the current federal
Technical Requirements as described in the United states Accesi Board's 2011 Proposed Accessibility Guidelines for Pedestrian
Facilities in the Public Right-of-way Notice of Proposed Rulemaking (NPRM)'
lnformation
Fee
Encroachment/Placement Permit 5345.00
Fees that maY aPPIY
-A 5olo Technology Fee will be applied to the total cost of the permit for processing the application'
-A 51061.00 Asphalt deposit is required when the asphalt will be disturbed'
-Additional financial security may be required.
Deposits and Financial SecuritY
projects involving work within puUtic right of way in the City of Springfield are subject to deposits or other approved forms
offinancial securitythatmayincludep"rforr.n..bonds,set-asideletters,orirrevocablelettersof credit' Thetypeof
financial securityisdeterminedbytheproject'ssize,scope,andpotential impacttopublicinfrastructure. Examplesoftypical
impacts that will require financial security include asphalt trench cuts and sewer repairs that involve cuts to a main line.
Warranties
Financial security is held by the City during a warranty period that typically lasts one year and begins when the project
passes final construction inspection. The warranry period allows the City to monitor the structural integrity of repairs and
determine their long-term viability. Financial security provides the City with the means to repair infrastructure should
failures that remain uncorrected by the applicant or applicant's representative occur during the warranty period. A final
warranty inspection will be conducted eleven months after the final construction inspection. Financial security will be
released when the warranty period has passed final inspection.
Restoration of City facilities
It will be determined by the Public Works Director at the time of the 1 I month inspection as required in Municipal
Code 3.222 that the work area in the public right-of-way is in as good a condition or better than it was before the
issuance of the encroachment permit.. Municipal Code 3.210 (2).
When do you need an Encroachment permit?
Municipal code 3.208 Work On or Under Surface-Encroachment Permit Reouired (http://www.qcode.us/codes/springfield/)
defines when you need an encroachment permit.
When do you need a Placement permit?
Municipal code 3.224 Placement of Devices or Structures in the Public Way ( http://ww.qcode.us/codesl5pringfieldl defines
when you need a placement permit.
Step 5: Signature
Signature Date:
l- Applicant ff Contractor T Utility Project ManagerA_
red to call: The Lane Utif/ties Coordinating Council's "One Call Number" 1-800-332-2344,
48 hours before before digging.
Check one:
You requr
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