HomeMy WebLinkAboutPermit Sidewalk 2019-06-05Driveway/Sidewal k Permit Application
ofSpringfield
Application Date:
Permit Number
lssue Date:Hffi225 Fifth Street, Springfi eld, Orcgon 97 477
Transportation & Engineering Section, Public Work Department
Phone: 54'l 726-3753
SITE INFORMATION
Location of Work:P-n'r t-
Applicant:
Address:
City:
Lt\5 +..
rhone:
Tax Map
Tax Lot
eq*%zt b
<ftlrr'iohJ t) state: fT zt*(i[-\1b--
Subdivision
Ownen
Address:
City:
Phone:
State:ZIP:
REQUESTED PERMITS:
Fees
f Sidewalk Amountofsidewaikinexcessof90feet
$Sidewalk
Renair
l- Curb CuVDriveway: Number of Driveways_
E Multiple Permit Discount each: (Maximum 2)
fvlulti permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits only. Not sidewalk repairs
p%TechnologYfee
l_ Proof of lnsurance: 5500,000 Minimum if work is done by property owner,
f Facility Meets 201 1 PRoWAG For ADA Compliance
5 1 21.00 l st Cut X 565 2nd Cut
Total due with permit 5
s121.00
slzs
@50.11 5F
CONIRACTOR'5 INFORMATION
Name:
Address:
City:
Phone:
State:ZlP:
Contractor Registration #
Project 5upervisor
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/permitnumber,jobaddress,
typeofinspectionrequested,andwhenyouwillbereadyforinspection,Contractor'sorOwner'sname,andphonenumber. Requests
received before 7:00 am will be made the same day, requests after 7:00 am will be made the next working day. Inspections are to be
called in after excavations are made and form work is in place, but prior to pouring concrete.
are to ng 48 hours
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 certify that all information herein
istrue and correct, and I further certify 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 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 speciry, 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 permiuee.
I further agree to ensure that I at the proper time that project address is readable from the street and
construction.the approved set of plans
Signature
on the site at during
our,fglna ),2oi
t_: