HomeMy WebLinkAboutPermit Sidewalk 2019-06-07aI
y/Sidewalk Permit A
City of Sprinqfield
licationpDrivewa
Application Date:
Permit Number
Issue Date: ]rur225 Fifth street, Springlield, Oreg on 97477
Transportation & Engineering Sectlon, public WorlG Departmentphone:54.1 726_3753
SITE INFORMATION
Location of Work:
.-L-/,A'<y'
Appiicant:
Address:
City:
'z Phone:
Tax Map
Tax Lot
ZIP:7
Subdivision
Owner
Address:
:.Lrty:
Phone:
State:ZIP:
REQUESTED PERMITS:
l: Sidewalk Amount of sidewalk in excess of 90 feet
I Sidewalk Repair
.fiurb Cut/Drivewayt Number of Driveways _
f iVtultiple Permit Discount each: (Maximum 2)
IVlulti permit discount good for one site and one site inspection only
applies to 2nd and 3rd permits oniy. Not sidewalk repairs
[: 5% Technology fee
f Proof of Insurance: 5500,000 Minimum if work is done by property owner.
[: Facility Meets 201 1 PROWAG For ADA Compliance
Fees
121.00 @s0.1 1 5F
5121.00 'l st Cut X 565 2nd Cut
S41
Totaldue with permit S
CONTRACTOR'S INFORMATION
Name:
Address:
City:
(2 /4C>L(.L Phone:
e
ZIP:
Contractor Registration #
Project Supervisor
Expiration date:
A
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 ca Lane Coordinating Council's "One Ca Nu 1 -800-332-2344, 48 hours before
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 certifr that all information herein
is true and correct, and I further certifu that any and all work performed shail be done in accordance with the Ordinances of the 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 specify, 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
are requested at the proper time that project address is readable from the street and
the approved set of plans will
*nW6 o.88
ired
Signature
on at all times during construction.
Date:6 /?
to the permittee.
I further agree to ensure that all