HomeMy WebLinkAboutPermit Encroachment 2019-08-16Application to Work in the Right of Way
You will need to complete application, save as, then attach to
email or print and bring to Public Works City Hall.
You wlll need to cometo Publlc Works, City Hall to process permlt.
ofSpringfield
This application can be emailed to .gov.225 Fifth Street
Springfi eld, Oregon 97 477
Engineering & Transportation Services Division
Phone (541) 726-37s3
Step 1-Location of Work
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Who is filling out the application?
ln this section, you will need to identif 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 :L'ea t %b t{th s+, 35S D St.raxMap l7b13S7c1
Applicant:
Email Address:
Owner:
Address:
City:
Contractor:
Contractors Registration (CCB) #:
Project Supervisor:
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ZIP:
Phone:
Phone:
Expiration Date:
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[- Proof of lnsurance, minimum 5500,000 coverage limit
State:
Utilities
Does your utility compony have a franchise agreement or license with the City?
PleaseidentifywhichtypeofagreementyoucurrentlyhavewiththeCity. f FranchiseAgreement 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 type 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 bacKill material to be used.
-Provide the start and end dates, start time of day and end time of day, of your project. lt is important that you give
time of day that you are requesting for your project work. There are codes and inspections that are time sensitive.
-ldentify your method of intrusion into the surface of the right of way, such as cut, bore, or drilling.
-Describe the surface area length, width, depth, and height ofyour 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.
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f Repairing/maintaining existing facilities
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Project
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Print Form
Once the application hos been approved, a permit will be issued
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Driveway/Sidewalk Permit Application
City of Springfield
Application Date:
Permit Number
lssue Date:
225 Fifth Street, Springfield, Oregon 97477
Transportation & Engineering Section, Public Works Department
Phone: 541 726-3753
SITE INFORMATION
Location of Work:
Applicant:
Address:
City:
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Phone:sY,- .{tJ - 7 61 3
State: 0 ZIP:qTWl raxMap l7Ol"S?9
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Subdivision
Owner:
Address:
City:
REQUESTED PERMITS:
f Sidewalk Amountofsidewalkinexcessof90feet
[- Sidewalk Repair
[- Curb Cut/Driveway: Number of Driveways_
T 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
f- 5olo Technology fee
[- Proof of lnsurance: 5500,000 Minimum if work is done by property owner.
f Facility Meets 201 1 PROWAG For ADA Compliance
5125.00 lstCut X567 2ndCut
Phone:
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Total due with permit 5
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Fees
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CONTRACTOR'S
Name:
Address:
City:
Contractor Registration #
Project Supervisor
State: 0 ZIP:
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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.
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
called in after excavations are made and form work is in place, bLrt prior to pouring (onoete.
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SIGNATURE:
Amount Received:
Receipt No.
Date Paid:
Received By:
By signature, I state and agree that I have carefully 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 with the Ordinances of the City of
Springfield applicable City Standard specifications and drawings and the laws ofthe 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 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 site at all times during construction.
Signature Date:f/ta/t'
INFORMATION
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Period of use or time of construction: 7am to 6 pm onlv, unless it's an emergency.
From Date:To Date:
Daily Start Time:Daily End Time:
STOP: Answer these questlons next
; Are you working in the right of way or connecting to City facility? lf yes, continue at Step 2a: Work Site Area
T 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
l- Cut l- Bore Other:
Length Depth width Height
Existing Surface Material:
Surface replacement material to be utilized:
Backfill material to be utilized:
System Connections to City lnfrastructure
Directions: Submit plans that identify in detail the scope of work to be performed in the City right of wayleasement. The work shall be
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.
T Wastewaterconnection [- Stormwaterconnection
l- To Stub [- Catch Basin/Bubbler
l- Main Line [" Stub
[- Other: l- Main Line
Description:
Safety and Environment Counc'rl's tOne Call f.lumbe/
81 1 or 1-800-332-2344
Air Qualiltr
Type of Dust Control to be utilized
48 hours before digging
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
discharge of sediment and other pollutants to the public stormwater system. Call LDAP with questions, \,1t1 I )6 548.9.
Listed below are some of the most common issues on right of way construction projects. How will you address these items on your
SWPPP? Please be aware that each project is unique and may present challenges not addressed in this set of examples.
[- Dewatering f- Soil Erosion l- Hazardous material storage/spill prevention
l- Sawcut slurry runoff T Site runoff/sedimentation
Wastewater Spill/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 takeall reasonableprecautiontoavoidspillsandshall immediatelynotifyCityofSpringfieldMaintenance-c.it 776 3ot5 or
54't 7)C i/ci; After horrrs I rjr€'rqency RespoIsc lei::r 54i 95-l ,l47ti inthe eventof aspill.
Plan submittal for Wastewater main line work
[* Bypass pumping [- Temporary plugging of sanitary main
Traffic Control Plan Criteria for Citv of Springfield 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 CICP) with the following information on 8.5"x1 l " or 1 1"xl7" paper. Fill out and submit this form with
your TCP.
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_l
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. ODOT's Traffic Control Handbook website: urwur.
oregon.oov/Oqot:l7HWY/TRAFFIC-ROADWAY/docs&dflQl-TeH 06.pdf?ga=t
f Traffic Control Plan attached in email to Land Development; LDS@springfield-or.gov
- No Traffic Control PlanI Th"r".r" no public traffic safety issues with this application.
What kind of work plan do you need?
You will need to submit a copy of the work plan, which includes:
\y\7^ite location and vicinity map r ldentify extent of excavations
I include North arrow. ' or bore locations.
- Outline limits of disturbance/I of work area. Show location of utilities within right of way. ldentify pipe
- identify staging/material f size and type' mainline connection location' and
srorage areas. connection tYPe'
Work Plans attached in an enrailto Land Develcpment; serrd to LDSgspringfield or gov. Re{erence site location and name in sub;ect 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 S345.00
Fees that may apply
-A 5olo Technology Fee will be applied to the total cost of the permit for processing the application.
-A $ 1 061 .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
of financial security that may include performance bonds, set-aside letters, or irrevocable letters of credit. The type of
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
failures that remain uncorrected by the applicant or applicant's representative occur during the warranty period. A final
warranty inspection will be conducted eleven months after the final construction inspection. Financial security will 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 I 1 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?
Municipal code 3.208 Work On or Under Surface-Encroachment Permit Required (http://www.qcode.us/codes/springfield/)
defines when you need an encroachment permit.
When do you need a Placement permit?
Municioal code 3.224 Placement of Devices or structures in the Public Wav ( http://ww.qcode.us/codeslSp-,ringfteldl defines
when you need a placement permit.
Step 5: Signature
Signature
Check one:
Date:
[- Owner l- Applicant [- Contractor [- Utility Project Manager
You are required to call, the Lane Utilities Coodinating Councils lOne Call tlum
Y flblf
48 hours before before digging.
ber" 1 -800-332-2344,
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