HomeMy WebLinkAboutPermit Sidewalk 2019-09-05IL s
aDrivewayl ewalk Perrnit Application
ofSpiingfield
Appiication Date:
Permit Number
Issue Date:
m 225 Fifth Street, Springfield, Oregon 97477
Transportation & Engineering Section, Public Worls Department
Phone: 541 726-3753 Hffi
SITE iNFORMATION
Location of Work:
Appiicant:
Address:
City:statel & zPl
5t
Tax Map
I ax Lot
State:ZIP:
Subdivision
Ownen
Address:
City:
REQUESTED PERMffS:
(siaewatt Amountofsidewalkinrrcc;rf gofeet H)t' +OiAl
l- Sidewalk Repair
$Z Curb Cut/Driveway: Number of Drive*ryt /
f 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
ifrsxt"cn"olosY
fee
' f Proof of lnsurance: $500,000 Minimum if work is done by property owner.
CONTRACTOR'S INFORMATION
Phone:
114.00
Fees
@s0.10 sF
114.00 1 st Cut x561 2nd Cut
Totai due with permit S
Phone: $i{f.4?fC.ilO I
dtsn.arrt M
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Name:
Address:
City:
Contractor
State: (L ZIP:tl4'rt
Expiration date:
Project Supewisor
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 cail: 541 726-3769 (recording) State your designated City job number/permit numbel 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
cailed in after excavations are made and form work is in place, but prior to pouring concrete.
are requ to ca 5 l -800-332-2144,
-18 hours before before digging.
SIGNATURE
Amount Received:Date Paid:
Receipt No.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 certiry 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 ofthe State of Oregoh pertaining to the work described
herein, I further certify that only contractors and employees who are in compliance with ORS 70'1.055 will be used.
The City may inspect the work site described in this permit at any time during a one year period foilowing 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 acceptab le to the City. The permittee witl 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 permitte€
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 pians will remain on the site at all times during construction.
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