HomeMy WebLinkAboutPermit Sidewalk 2019-06-06DrivewaylSidewalk Permit Application
lcity ofSpringfield
Application Date:
Permit Number
lssue Date:
225 Fifth Street, Springfield, Oregon97477
Transportation & Engineering Section, Public Work Depaftment
Phone: 541 726-3753 HffiT
STTE INFORMATION
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Address:
phone:W1 ZZL0/10_ ',
Subdivision
Owner:
Address:
City:
Phone:
State:zlP..
REQUESTED PERMITS:
Fees
[] Sidewalk Amount of sidewalk in excess of 90 feet
l- Sidewalk Repair
ft Curb CuVDriveway: Number of Driveways I
f ft4ultipie Permit Discount each: (Maximum 2)
fululti permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
l- 5% Technology fee
l- Proof of lnsurance: 5500,000 Minimum if work is done by property owner,
f Facility Meets 201 1 PROWAG For ADA Compliance
S121.00 15tCut X 565 2nd Cut
Total due with permit S
S rz1:oo
s22.00
@s0.1'l sF
CONTRACTOR'5 INFORMATION
5#a u ex Phone:Name:
Address:
City:State:ZIP:.
Contractor Registration #
Project Supervisor
Expiration date:
Phone:
INSPECIIONS:
An insp€ction request should be made prior to pouring concrete, after the proposed work has been formed and made ready to pour.
Curbcutandsidewalkinspectionscall:541 726-3769 lrecording)StateyourdesignatedCityjobnumber/permitnumber,jobaddress,
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 am will be made the same day, requests after 7:00 am will be made the next working day. lnspections are to be
called in after excavations are made and form work is in place, but prior to pouring concrete.
are to Nu
SIGNATURE:
Amount Received:Date Paid:
Received By:Receipt No.
By signature, I state and agree that I have carefully examined the completed application and do here by certiry that all information herein
is true and correct, and I funher certiry that any and all work performed shall be done in accordance with the Ordinances ofthe City of
Springfield applicable City Standard specifications and drawings and the laws ofthe State of Oregon pertaining to the work described
herein, lfurther certify that only contractors and employees who are in compliance with ORS 701.055 will be used.
The City may insp€ct the work site described in this permit at any time during a one year period following receipt by the City of notice of
completion of the described work and specify, at the City's sole discretion, any additional restoration work required to retum 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 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 further 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 plans will remain on the site at all times during construction.
Signature Date:
Tax Map
Tax Lot
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