HomeMy WebLinkAboutPermit Encroachment 2019-06-21Reset Form Print Form
Application to Work in the Right of Way
Once the application has been approved, a permit will be issued
in ofSplingficld
will need to complete application, save a!, then atta<h to
will need to come to Public Works, City H.ll to process permit.
or print and bring to Public Works City Hall.
is application can b€ emailed to LDS@springfield-or.gov225Street
Springfi eld, Oregon 97 477
Engineering & Transportation Services Division
Phone (541 ) 7263753
Step 1-Location of Work
Who is fillino out the application?
ln this section, you will need to identify the Applicant, Owner of the abutting property, and the Contractor, if applicable.
Example:
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 : 2245 1 9th Street Tax Map
Tax LotApplicant: Rainbow Water District
Email Address: eric@rwdonline.net Phone:54'l-954-9941
H?I
Owner:
Address:
City:
Phone:
State:ZIP:.
Contractor: RainbowWaterDistrict Phone:541-746-1676
Contractors Registration (CCB) #:
Project Supervisor: Eric Carlson
lnsurance
l- Proof of lnsurance, minimum 5500,000 coverage limit
Expiration Date:
Phone: 541 -954-9941
Utilities
Does your utility compony hove a franchise agreement or license with the City?
Please identifo which type of agreement you currently have with the City. f 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 tvpe 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, ofyour project. lt is important that you give
time ofday that you are requesting for your project work. There are codes and inspections that are time sensitive.
Jdentify your method of intrusion into the surface ofthe right ofway, such as cut, 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.
f Placing new facilities in the right of way
lX Repairing/maintaining existing facilities
16" steel water main and or repair water service line feeding 2245 19th St. We Plan to cut a 3' X 5' hole in the edge
Project
Description:
roadway, between the the bike lane and the curb and gutter pan to repair the water service line. lf the repair work
uires it we may need to remove the adjacent driveway wing and sidewalk panel. We will return all surfaces to original
Bacffill will becompactedcrushedrockandC.D.F. Wewill coveranyandall holesinroadwaywithsteel plates
if required.
Period of use or time of construction: Tamto 6 pm only. unless it's an emergency.
From Date: 6-20-19 To Date: 6-21-19
Daily Start Time: 7:304M Daily End Time: 5:00PM
STOP: Answer these questions next
y Are you working in the right of way or connecting to City facility? lf yes, continue at Step 2a: Work Site Area
f Are you storing material/objects in the right of way other than during hours of work? lf yes, continue at Step
3: Submit a Work Plan
Step 2a: Work Site Area
X Cut f Bore Othen
Length 5' Depth 4 width 3'Height
Existing Surface Material: AC and Concrete
Surface replacement material to be utilized: Cold mix AC until final paving
Backfill material to be utilized: 3/4" crushed rock and C.D.F. as required
System Connections to City lnfrastructure
Directions: Submit plans that identify in detail the scope of work to be performed in the City right of way/easement. The work shall b€
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.
[- WastewaterConnection l- StormwaterConnection
l- To Stub [- Catch Basin/Bubbler
l-- Main Line J- Stub
[* Other: l- Main Line
Description:
Safety and Environment
Air Quality
Type of Dust Control to be utilized:
Stormwater Pol lution 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
dischargeofsedimentandotherpollutantstothepublicstormwatersystem.Call LDAPwithquestions,r1l.'26r.181,.
Listed below are some of the most common issues on right of way construction projects. How will you address these items on your
SWPPP? Pleasebeawarethateachprojectisuniqueandmaypresentchallengesnotaddressedinthissetofexamples.
X Dewatering l- Soil Erosion I-- Hazardous material storage/spill prevention
X Sawcut slurry runoff l- Site runoff/sedimentation
Wastewater Spi I l/Overflow Prevention
Directions: City policy requires that all work performed in the City right of wayleasement 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 takeafl reasonableprecautiontoavoidspillsandshall immediatelynotifyCityofSpringfieldMaintenance54l 726'3615 ot
54 1 /26 3/ 61 , After hou rs Errergency Response Teanr 541 953 3428 in the event of a spill.
Plan submiftal for Wastewater main line work
[- Bypass pumping l- Temporary plugging of sanitary main
Traffic Control Plan Criteria for City of Sprinofield 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 Submittal requirements:
Submit your Traffic Control Plan OCP) with the following information on 8.5"x1 1" or 1 1 "x1 7" paper. Fill out and submit this form with
your TCP.
Page 2 of 3
Vo[are reqriirea to iaii: ihe Lani utitiiiis Cooid,nrting aouncil('6ne tifi tlumbei';
81 1 or 1-800-332-2344
48 hours before digging.
The TCP shall be a legible hand drawing, or a computer aided design with the following information:
Traffic Control Plan form is located at www.springfield-or.gov/menuonlineforms
A vicinity map:
That includes the north arrow, road names, intersection/driveway access points, curb lines, the work zone, and any special features such
as buildings, access points, sight obstructions, that could affect the TCp.
Location:
Where will the TCP be active? This can be a line drawing of the work zone(s) and/or a map that clearly indicates where traffic control
devices will be placed, including spacing and cone tapers.
Attachments of the appropriate traffic control diagram(s) as shown in the current MUTCD and/or the ODOT Oregon Temporary Traffic
Control Handbook that reflect the work zone may be included as a standard reference. oDoTs Traffic Control Handbook website: www.
oreqon.gov/ODOT/HWY/TRAFFIC-ROADWAY/docs/odf/OTTCH 06.pdpoa=t
I Traffic Control Plan attached in email to Land Development; LDS@springfield-or.gov
No Traffic Control Plan # ,l .-lsot-3 /on*t-7There are no traffic safety issues with this
U ta an
What kind of work plan do vou need?
You will need to submit a copy of the work plan, which includes:
- site location and vicinity map - ldentify extent of excavations' include North arrow. l^ or bore locations.
- Outline limits of disturbance/I of work area. Show location of utilities within right of way. ldentify pipe
- identifo staqinq/material |X size and type, mainline connection location, and
L- - '' connection type.storage areas.
Work Plans attached in an email to Land Development; send to LDs@springfield-or.gov. Reference site location and name in subject line.
*Construction of ADA ramps or other ADA facilities require submittal of detailed topographic survey and design sheets stamped
byaProfessional EngineerlicensedintheStateofOregon. DesignofADAfacilitiesshall ataminimummeetthecurrentfederal
Technical Requirements as described in the United States Access 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 S335.00
Fees that may apply
-A 50z6 Technology Fee will be applied to the total cost of the permit for processing the application.
-A 51030.00 Asphalt deposit is required when the asphalt will be disturbed.
-Additional financial security may be required.
Deposits and Financial Security
Projects involving work within public right of way in the City of Springfield are subject to deposits or other approved forms
offinancial securitythatmayincludeperformancebonds,set-asideletters,orirrevocablelettersofcredit. Thetypeof
financial security is determined by the project's size, scope, and potential impact to public infrastructure. Examples of typical
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 warranty 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
failuresthatremain uncorrectedbytheapplicantorapplicant'srepresentativeoccurduringthewarrantyperiod. Afinal
warrantyinspectionwill beconductedelevenmonthsafterthefinal constructioninspection. Financial securitywill 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 3.21 0 (2).
When do you need an Encroachment permit?
Municioal code 3.208 Work On or Under Surface-Encroachment Permit Reouired (htto://www.ocode.us/codes,/sprinqfield,/)
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 Wav ( htto://www.qcode.us,/codes,/sorinqfield, defines
when you need a placement permit.
Step 5:
Signature
Signature
Check one:
Eric Carlson
f Owner
Vou are iequ
T Applicant i* Contractor
ihe Gne uiiiiiiesaooidinaiins
X Utility Project Manager
Council's "One Call Number'; t
I
ired to call:
48 hours before before digging.
Page 3 of 3
Date: 6/19/19
By signoture, I stote I hqve corefully exqmined the opproved permit ond do hereby qgree to comply with
the requirements of the permit ond I certify ony ond oll work performed sholl be done in occordonce with
the Ordinonces of the City of Springfield, opplicoble City Stondord Specificotion ond Drowings, ond the
lows of the Stote of Oregon pertoining to the work described herein. I further certify only controctors ond
employees who ore in complionce with ORS 701.055 will be used for this project.
I ogree for myself, my contrqctors, ond employees, thot the opprovol of the right of woy permil in no
monner presumes or implies the opprovol or terms of opprovol of ony other future permit required by the
City for the site qnd indemnifies ond holds hormless the Cily regording ony future opprovol of o future site
plon, portition, subdivision, or ony other required permit thot moy cquse ony work completed in
complionce with the right of woy permil to be qltered to conform to the finol permit opprovol.
I understond ond ogree the City moy inspect the work sile described in this permit ot ony time during o
one-yeor period following the receipt by the City of notice of complelion of the described work ond
specify, ot lhe City's sole discretion, ony odditionql restorotion work required to return the site to o
stondqrd occeploble lo the City. I will be notified in writing of ony work required qnd will hqve 30 doys
from the dote of the notice to complete the work. Work not completed qt the end of the 30 doys will be
performed by the City ond the costs will be billed to me.
I further ogree lo ensure oll required inspeclions ore requesled ot the proper lime ond the opproved
permit ond sel of plonr will remoin on lhe site ot oll times during conslruclion qnd until removed by
the Cily.
I shqll defend, indemnify qnd hold hormless the City from ond ogoinst oll liobility or loss ond ogoinst oll
cloims or qctions bosed upon or orising out of domoge or iniury to persons or property coused by or
sustoined in connection with performonce if this Controct by the permittee except, pursuont to ORS 30.140,
for losses, cloims, or octions resulting from the sole negligence of the City.
I sholl ossume oll responsibilities for the work, qnd beor oll losses ond domoges directly or indirectly
resulting to the permittee, the City, or to others on occount of the chorocter or performonce of the work,
unforeseen difficulties, occidents, or ony other couses whotsoever. I sholl qssume defense of, indemnify
qnd sove hormless the City, its officiols, qgents, ond employees from oll cloims, liobility, loss, domoge, ond
iniury of every kind, noture ond description, direclly or indirectly resulting from octivities in the
performonce of the Controct, the ownership, mointenonce or use of motor vehicles in connection therewith,
or the ocls, omissions, operotions, or condua of the permittee or ony Subcontroctor under the Controct or
ony woy orising out of the Contrqct, irrespective of whether on oct, omission or conduct of the City
connected with the Contrqct is o condition or contributory couse of the cloim, liobility loss, domoge or iniury
ond irrespective of whether oct, omission, or conduct of the permittee or Subcontroclor is merely o
condition rqther thqn o couse of o cloim, liobility, loss domoge or iniury. I sholl not be lioble for, nor be
required to defend or indemnify, the City relotive to cloims for domoge or domoges resulting solely from
qcts or omissions of the City, its officiols, ogents, or employees. The permittee's obsence of or inodequocy
of the liqbility insuronce required by the City of Springfield shqll not negote permittee's obligotions in this
ogreement.
PERMITTEE:
Printed Nome:
Signoture:
Dote: <-l
Cityof Springfield o 225 FifthStreet o Springrfield,OR97477 . 54L.125.3153 o 541.736.1021 Fax
www.spri ngfi eld-or.gov
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