HomeMy WebLinkAboutPermit Sidewalk 2019-03-01Driveway,/Sidewalk Permit Application
ary Springfield
Application Date:
Permit Number Hffi-T
225 Fifth Street, Springfield, Orcgon97477
Transportation & Engineering Section, Public Works Department
Phone: 541 726-3753
lssue Date:
SITE INFORMATION
Location of Work:
Address:
City:
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stateQf_ zre: c1-lqY'l
*1(.119-loau(\h
Phone:
Tax Map
Tax Lot
Subdivision
Ownen
Address:
City:State:ZIP:
REQUESTED PERMITS:
l- Sidewalk Amount of sidewalk in excess of 90 feet _
$sidewalkRenair 3X LL
J- Curb CuUDriveway: Number of Driveways_
l- 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
)Q,5% Technology fee
f- Proof of lnsuranee: 5500,000 Minimum if work rs done by property owner
l- Facility Meets 20.l 1 PROWAG For ADA Compliance
Fees
121 .00 @s0.1 1 sF
5121.00 lstCut X565 2ndCut
Phone:
Total due with permit 5 b'i,3?il
CONTRACTOR'5 INFORMATION
Name:
Address:
City:
Phone:
State:ZIP:
Contractor Registration #
Project Supervisor
Expiration date:
Phone:
iNSPECTIONS:
An inspection request should be made prior to pouring concrete, after the proposed work has been formed and made ready to pour.
Curbcutandsidewalkinspectionscall:541 726-3769(recording)StateyourdesignatedCityjobnumber/permitnumbeljobaddress,
type of inspeaion 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 required to call:ng ne 1 2-23M,48 ing.
SIGNATURE:
Amount Received:
Receipt No.Received By:
By signature, I state and agree that I have carefully examined the completed application and do here by cenifo that all information herein
is true and correct, and I further cenify that any and all work performed shall be done in accordance with the Ordinances of the City of
Springfield applicable City Standard specifications and drawings and the laws ofthe State ofOregon 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 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
Date Paid:
Signature
I times during construction.
Date:
'l*
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