HomeMy WebLinkAboutPermit Sidewalk 2019-07-05Driveway/Sidewa I k Perm it Appl ication
City ofSpringfield
Application Date:
Permit Number
lssue Date:
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-?U/ 225 Fifth Street, Springfiel d,otegon97477
Transportation & Engineering Section, Public Works Department
Phone: 541 726-3753
SITE INFORMATION
Location of Work:
Applicant:
Address:
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Phone:<7-//-qfr- ]**o
Tax Map
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Subdivision
Owner:
Address:
City:
Phone:
FeesREQUESTED PERMITS:
[- Sidewalk Amountof sidewalkinexcessof90feet-
,/sidewalkRelair
/4utb Cult)riveway: Number of Driveways
f Multiple Permit Discount each: (Maximum 2)
Multi permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
y'svoTechnology tee
l- Proof of lnsurance: 5500,000 Minimum if work is done by property owner'
Facility Meets 2011 PROWAG For ADA Compliance
State:ZIP:
State: a-A+ZIP:
25.00
5125.00 lstCut x567 2ndCut
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542
Total due with permlt S
f
CONTRACTOR'S I
Name:
Address:
City:
Phone:
l 4l
#o-S -.tContractorExpiration date:
Phone:
Project SuPervisor
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,
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
is in place, but prior to pouring con(rete'
called in after excavations are made and form workffi I\ "Oneaall Number" 1€00J32-2344,48 hours before re digging.
SIGNATURE:
Amount Received:
to the permittee.
I further agree to ensure that i
the approved set of Plans will
Date Paid:
Receipt No. Received BY:
By signature, l state and ug,"".h* l h*".*"fully examined the completed application and do here by certify that all information herein
is true and correct, and I further certify that any and all work performed shall be done in accordance wiih the ordinances of the city of
Springfield applicable City 5o"al"ri Jp".iri.rtions and a'awings ;na the laws of the State of oregon pertaining to the work described
herein, I further certify that only contractors and ".ptoy"., *io ure in compliance with oRS 70'l'055 will be used'
The city may inspect the work;iie described in this permit at any time during a one year,period following receipt by the city of notice of
completion of the described *.rr "Jip..itv, ut tt "
city's 'ol" iiit'etion' a'iy udditional restoration work required to return the site to a
standard acceptable to the city. The permittee will oe.notineJin *rliing or any work required and will have thirty days (30) from the date
of the notice to comprete the work not compreted at ttre ena'oi'iie it ifv auvr *irr be performed by the city and the costs will be billed
at the proper time that proiect address is readable from the street and
construction.
Signature
all required
Date:1-<-t1'