HomeMy WebLinkAboutPermit Sidewalk 2019-05-07Drivewaylsidewa lk Permit Appl ication
lcity Springfield
Application Date:
Permit Number
lssue Date:
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225 Fifth Street, Springfield, Orcgon 97477
,Transportation & Engineering Section, Public Work DepartmentI Phone: 541 726-3753
SITE INFORMATION
Locationofwork 5925 r ,t
npplicant fl
Address:
City:*trD State:
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Tax Map
Tax Lot
Subdivision
Ownen
Address;
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Phone:
State:ztP..
REQUESTED PERMITS:
l- Sidewalk Amountofsidewalkinexcessof90feet
[- Sidewalk Repair
E\Curb CuUDriveway: Number of Driveways7-' 5 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
;( 5% Technology fee
l- Proof of lnsurance: 5500,000 Minimum if work is done by property owner.
f Facility Meets 201 1 PROWAG For ADA Compliance
Fees
121 @s0.1 1 sF
S1 21.00 1 st Cut X 565 2nd Cut
s41
Totaldue with permit 5
CONTRACTOR'5
Name:
Address:
City:
-n?ffnier (lrerr) ,n"^",541'5Ll-zgbs
State:ZIP:
Contractor Registration #
Project Supervisor
Expiration date:
Phone:
INSPECTION5;
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,
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. lnspections are to be
called in after excavations are made and form work is in place, but prior to pouring concrete.
SIGNATURE:
Amount Received:lZ1 , o{9 Date Paid:0<- ad-t1
Receipt No. 47fl <,t{ Received By: -S;-eUi
-
By signature, I state and agree that t have carefully examined the completed application and do here by cenify that all information herein
is true and correct, and I further certifo 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 Iaws 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 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 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
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Signature Date: