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Home My WebLink AboutPermit Sidewalk 2019-08-29TH C7R6E rtlr..l6Fl€LDApplication Date Permit Number lssue Date: SITE INFORMATION Location of Work: 1 70 16th Street 225 Fif gRgGON Applicant: Bob Tate 1-914-9918 Tax Map 1 7-03-36-31 Tax Lot 4701 Address: City:Eugene P.O.Box26423 state: oR zlP: 97,402 tionDriveway/Sidew City of Springfield n/a (Land Partition pending; see Case No. 81 1-19-000034-TYP2)Subdivision Owner: Address: City: Bob & Sharon Tate 465 Wilkes Drive Eugene State: OR ZIP: 97,404 Phone: ls+r -or +-eor a REQUESTED PERMITS: X Sidewalk Amount of sidewalk in excess of 90 feet l- Sidewalk Repair X Curb Cut/Driveway:Number of Driveways 1 51 21 .00 $22.00 X S121.00 lstCut S+t Totaldue with permit $ Fees @s0.1 1 5F X 565 2nd Cut X 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 X 5o/o Technology fee X Proof of lnsurance: S500,000 Minimum if work is done by property owner lX Facility Meets 201 1 PROWAG For ADA Compliance CONTRACTOR'S INFORMATION Dynasty Concrete Co. (Contact: Bob Tate)Phone: 541-914-9918 Address:P.O.Box26423 Name: City:Eugene State: OR ZIP:97,402 # Oregon CCB License #187590 Expiration date:2019-07-31Contractor Registration Project Supervisor Phone: 51 l-551 -n\l I 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: 54,l 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 called in after excavations are made and form work is in place, bi;t ;lrior trl pourirrg (orrcret.l u are required to call; The Lane Utilities Coor ainaiing Council's "One CaII Number" 1-800-332-2344,48 hours before before dlgging SIGNATURE: Amount Received: Receipt No. By signature, I state to the permittee. I further agree to ensure that the approved set of Plans wil Date Paid: Received By: and ag ree that I have carefully examined the completed appli cation 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 don e in accordance with the Ordlnances of the City of Springfield applicable City Standard specifi cations and drawings and the laws of the State of Oregon pertaining to the work described herein, I further certify that only contractors and employees who 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 of the described work and specify,at the City's sole discretion, any additional restoration work required to return the site to a standard acceptable to the City. The permittee will be notified in writing of any work requ ired 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 perform ed by the City and the costs will be billed all required inspections are requested at the proper time that project address is readable from the street and the site at all times during construction. Signature on Date Transportatio " - CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 812912019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS GERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF TNSURANCE DOES NOT CONSTTTUTE A CONTR.ACT BETWEEN THE ISSU|NG TNSURER(S), AUTHORTZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER. IMPORTANT: lf the certificate an ADDITIONAL INSURED, the policy(ies) must be endorsed. lf SUBROGATION lS WAIVED, subject to the terms and conditions of the certificate holder in lieu of such policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the PRODUCER DUSTTN SArN (07589) 711 COUNTRY CLUB RD STE 203 EUGENE, OR 97401-0000 DUSTIN SAIN 541-334-7700 541-334-7707 DUSTIN AFFOROING COVERAGE A. COUNTRY Mutual lnsurance Company 20990rNsuRED 735g296 DYNASTY CONCRETE CO PO 8OX24124 EUGENE, OR 97402 INSURER B : INSURER C : INSURER E : INSURER F c CERTIFICATE BER:REVISION NUMBER: MAY ISTHIS TO CERTIFY THETHAT OFPOLICIES LIINSURANCE STED BELOW BEENHAVE TOISSUED THE INSURED ABOVENAMED THEFOR PERIODPOLICY NDICA.TED.ANYNOTWITHSTANDING REQUIREMENT ORTERM ITIONCOND ANYOF ORCONTRACT DOCUMOTHER WITHENT TORESPECT THISWHICH ,TECERTIFICA MA'ISSUBE ORED THPERTAIN INSURANCEE BYAFFORDED POLtCtTHE DESCRIES HEREINBED S ECTSUBJ ALLTO THE TERMS, EXCLUSIO NS DAN OFCONDITIONS POLICIES.SUCH LIIVITS SHOWN HAVEI\4AY REDUCEDBEEN PAIDBY TYPE OF INSURANCE LIMITS EACH OCCURRENCE $ MED EXP one PERSONAL & ADV 1 GENERAL AGGREGATE PROOUCTS -AGG $ A COMMERCIAL GENERAL LIABILITY GEN'L AGGREGATE LIMIT APPLIES PER: CLAII\,,IS-I\,IADE OCCUR POLICY LOC GENERAL LIABILITY 489236698 /2019 t31t2020 $ BODILY INJURY (Per person)$ BODILY INJURY (Per accident)$ $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON-OWNED AUTOS A89236698 t31t20'.t9 1t2020 $ EACH s 3,000,000UMBRELLA LIAB EXCESS LIAB OCCUR CLAII,,IS-MADE AGGREGATE A 4U9241728 112019 12020 E.L. EACH ACCIOENT E.L. DISEASE. EA WORKERS COMPENSANON AND EMPLOYERS'LIABIUTY in below ANY EXCLUDED?N/A E.L. DISEASE - POLICY $ LocATloNs/vEHlcLES (AttachAcoRDloi,AdditionarR6marksschedure,ifmorespaceisrequired)DESCRIPTION OF OPERATIONS / JOB NAME: 170 16TH STREET SPRINGFIELD OR ERTI LAT!ON o 1988-2010 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTTCE WILL BE DELIVERED IN ACCORDANCE wlTH THE POLICY PROVISIONS. CITY OF SPRINGFIELD 225 FIFTH STREET SPRINGFIELD, OR 97477 N^aAUTHORIZED REPRESENTATIVE ACORD 2s (2010/05)The ACORD name and logo are registered marks of ACORD Al! rights reserved. NAIC # INSURER D : CLAIMS. Y/Ntr AtL 10 67 0811 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTTCE OF CANCELLATTON TO CERTTFTCATE HOLDER(S) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE PART COMMERCIAL AUTO COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL PROPERW COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART RAILROAD PROTECTIVE LIABILITY COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART WORKERS GOMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY With respect to coverage provided by this endorsement, the provisions of the Coverage Part (Policy) apply unless modified by the endorsement. Cancellation The following is added under the Cancellation Condi- tion applicable to the Coverage Parts (Policy) listed above: lf we cancel this policy for any reason other than non payment of premium, we will mail written notice of cancellation to the certrficate holde(s) on file with the Company. Notice will be provided prior to the effec- tive date of cancellation. We will give the number of days notice as provided for in the Cancellation Condi- tion of this policy. The notice will state the effective date of cancellation. The policy period will end on that date. lf you cancel this policy, or if we cancel for non pay- ment of premium, we will mail written notice of such cancellation to the certificate holder(s) on file with the Company. The notice will state the date the policy was cancelled. The notice will be mailed by first-class mail to the last known mailing address of the certificate holder(s) on file with the Company. Any notice of cancellation provided by this endorse- ment applies only to the certificate holde(s) with a certificate of insurance applicable to this policy's period. Our failure to send notice of cancellation to the certifi- cate holder(s) will not amend, extend or alter the terms and conditions of this policy, including the can- cellation of this policy. lf there is a conflict between any other policy cancella- tion provisions pertaining to the certificate holder(s) and this endorsement, the other policy provisions shall control. Nothing contained here varies, alters, or extends any provisions of the policy except as provided in this endorsement. lncludes copyrighted material of lnsurance Seruices Office, lnc., with its permission. lncludes copyrighted material of American Association of lnsurance Services, lnc., with its permission. Contains copyrighted materia! of the Nationa! Council on Compensation lnsurance, with its permission. AIL 10 67 08 11 Page 1 of 1